Nokea
The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care?
- A. Risk for injury.
- B. Altered comfort level.
- C. Impaired circulation.
- D. Impaired skin integrity.
Correct Answer: A
Rationale: Confusion increases fall and injury risk, the priority problem in elderly postoperative clients. Comfort, circulation, and skin integrity are secondary.
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The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement?
- A. Notify the surgeon about the client's request to wear the medal.
- B. Tape the medal to the client and allow the client to wear the medal.
- C. Request the family member take the medal prior to surgery.
- D. Explain taking the medal to surgery is against the policy.
Correct Answer: B
Rationale: Taping the medal ensures safety (no loose objects) while respecting the client’s spiritual needs, per patient-centered care. Notification, removal, or policy citation are less accommodating.
The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching?
- A. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.
- B. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion.
- C. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume.
- D. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
Correct Answer: D
Rationale: Getting out of bed upright risks hip dislocation post-hip replacement; log-rolling is correct. Diaphragmatic breathing, foot exercises, and spirometry are appropriate.
The circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first?
- A. Include the sponge in the sponge count.
- B. Obtain a new sterile instrument pack.
- C. Tell the surgical technologist about the sponge.
- D. Throw the sponge in the sterile trashcan.
Correct Answer: C
Rationale: Telling the technologist ensures the contaminated sponge is removed from the sterile field, maintaining asepsis. Counting, new instruments, or trashing are secondary or incorrect.
Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected?
- A. Urine output was 160 mL in the past eight (8) hours.
- B. Paralysis and paresthesia of the right leg.
- C. T 99.0°F, P 98, R 20, and BP 100/60.
- D. Lungs are clear bilaterally in all lobes.
Correct Answer: D
Rationale: Clear lungs indicate no respiratory complications, expected post-hip replacement. Low urine output (20 mL/hr), paralysis/paresthesia, and mild hypotension suggest complications.
The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage?
- A. The 16-year-old client in the dorsal recumbent position having an appendectomy.
- B. The 68-year-old client in the Trendelenburg position having a cholecystectomy.
- C. The 45-year-old client in the reverse Trendelenburg position having a biopsy.
- D. The 22-year-old client in the lateral position having a nephrectomy.
Correct Answer: D
Rationale: The lateral position risks brachial plexus or peroneal nerve damage due to pressure on dependent limbs, especially during prolonged surgery like nephrectomy. Other positions have lower nerve risks.