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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 circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
- A. Prepare ice packs and mix dantrolene sodium.
- B. Request the defibrillator be brought into the OR.
- C. Draw a PTT and prepare a heparin drip.
- D. Obtain finger stick blood glucose immediately.
Correct Answer: B
Rationale: Tachycardia and hypotension suggest shock or arrhythmia, requiring a defibrillator for potential cardioversion. Dantrolene is for malignant hyperthermia, heparin for clotting, and glucose is unrelated.
The nurse is completing a preoperative assessment on a male client who states, 'I am allergic to codeine.' Which intervention should the nurse implement first?
- A. Apply an allergy bracelet on the client's wrist.
- B. Label the client's allergies on the front of the chart.
- C. Ask the client what happens when he takes the codeine.
- D. Document the allergy on the medication administration record.
Correct Answer: C
Rationale: Asking about the reaction verifies the allergy type (e.g., anaphylaxis vs. nausea), guiding safe care. Bracelet, labeling, and documentation follow verification.
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 is completing the preoperative checklist. Which laboratory value should be reported to the health-care provider immediately?
- A. Hemoglobin 13.1 g/dL.
- B. Glucose 60 mg/dL.
- C. White blood cells 6 (x10³/mm³).
- D. Potassium 3.8 mEq/L.
Correct Answer: B
Rationale: Glucose of 60 mg/dL indicates hypoglycemia, risking perioperative complications, requiring immediate HCP notification. Normal hemoglobin, WBC, and potassium are safe.
Which situation demonstrates the circulating nurse acting as the client's advocate?
- A. Plays the client's favorite audio book during surgery.
- B. Keeps the family informed of the findings of the surgery.
- C. Keeps the operating room door closed at all times.
- D. Calls the client by the first name when the client is recovering.
Correct Answer: C
Rationale: Keeping the OR door closed maintains privacy and asepsis, advocating for client safety. Audio books, family updates, and name use are supportive but less critical.