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The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery?
- A. The 65-year-old client who cannot read or write.
- B. The 30-year-old client who does not understand English.
- C. The 16-year-old client who has a fractured ankle.
- D. The 80-year-old client who is not oriented to the day.
Correct Answer: D
Rationale: Legal consent requires mental competency; disorientation to the day suggests incapacity. Illiteracy, language barriers (with interpreters), and minors (with parental consent) do not preclude consent.
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The nurse is assessing a client in the day surgery unit who states, 'I am really afraid of having this surgery. I'm afraid of what they will find.' Which statement would be the most therapeutic response by the nurse?
- A. Don't worry about your surgery. It is safe.
- B. Tell me why you're worried about your surgery.
- C. Tell me about your fears of having this surgery.
- D. I understand how you feel. Surgery is frightening.
Correct Answer: C
Rationale: Asking about fears encourages the client to express concerns, fostering therapeutic communication. Reassurance, asking 'why,' or assuming feelings are less empathetic.
The client one (1) day postoperative develops an elevated temperature. Which intervention would have priority for the client?
- A. Encourage the client to deep breathe and cough every hour.
- B. Encourage the client to drink 200 mL of water every shift.
- C. Monitor the client's wound for drainage every eight (8) hours.
- D. Assess the urine output for color and clarity every four (4) hours.
Correct Answer: A
Rationale: Fever post-surgery often stems from atelectasis; deep breathing and coughing prevent respiratory complications, the priority. Hydration, wound monitoring, and urine assessment are secondary.
Which problem should the nurse identify as priority for client who is one (1) day postoperative?
- A. Potential for hemorrhaging.
- B. Potential for injury.
- C. Potential for fluid volume excess.
- D. Potential for infection.
Correct Answer: A
Rationale: Hemorrhaging is a life-threatening risk in the first 24–48 hours post-surgery, the priority. Injury, fluid excess, and infection are secondary.
The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first?
- A. Notify the client's surgeon.
- B. Complete an occurrence report.
- C. Contact the surgical manager.
- D. Recount all sponges.
Correct Answer: D
Rationale: Recounting sponges verifies the discrepancy, the first step to ensure no retained objects. Notification, reporting, or manager contact follow if confirmed.
The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement?
- A. Determine why the client is not using the PCA pump.
- B. Document the amount and take no action.
- C. Chart the client is not having pain.
- D. Contact the HCP and request oral medication.
Correct Answer: A
Rationale: Determining why the client underuses the PCA (e.g., misunderstanding, side effects) ensures effective pain management. Documentation alone, assuming no pain, or changing medication is premature.