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The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?
- A. Alteration in comfort.
- B. Risk for depressed respiratory pattern.
- C. Potential for infection.
- D. Fluid and electrolyte imbalance.
Correct Answer: B
Rationale: Narcan reverses opioid-induced respiratory depression, but risk persists, requiring monitoring. Comfort, infection, and fluid imbalance are unrelated to Narcan.
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Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.
The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority?
- A. Assess the client's respiratory status.
- B. Monitor the client's urinary output.
- C. Take a 12-lead ECG prior to injection.
- D. Attempt to keep the client focused.
Correct Answer: A
Rationale: Procedural sedation risks respiratory depression; assessing respiratory status is critical for safety. Urinary output, ECG, and focus are secondary.
Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
- A. Surgical supplies were cleaned and sterilized prior to the case.
- B. The circulating nurse is wearing a long-sleeved sterile gown.
- C. Masks covering the mouth and nose are being worn by the surgical team.
- D. The scrub nurse setting up the sterile field is wearing artificial nails.
Correct Answer: D
Rationale: Artificial nails harbor bacteria, violating asepsis and risking infection, requiring immediate intervention. Sterilized supplies, masks, and long-sleeved gowns (if non-sterile role) are appropriate.