Nokea
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
- A. Apply antiembolism hose to the client.
- B. Attach the drain to 20 cm suction.
- C. Assess the client's vital signs.
- D. Listen to the report from the anesthesiologist.
Correct Answer: C
Rationale: Assessing vital signs establishes a baseline post-PACU, per ABCs. Antiembolism hose, drain attachment, and anesthesiologist report follow.
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The nurse is receiving a client from the postanesthesia care unit (PACU). Which interventions should the nurse implement? Select all that apply.
- A. Ambulate the client to the bathroom to void.
- B. Take the client's vital signs to compare with PACU data.
- C. Monitor all lines into and out of the client's body.
- D. Assess the client's surgical site.
- E. Push the client's PCA button to treat for pain during movement.
Correct Answer: B,C,D
Rationale: Vital signs establish a baseline, line monitoring ensures patency, and surgical site assessment detects complications. Ambulation is premature, and nurses cannot push PCA buttons.
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.
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
- A. Loss of sensation at the lumbar (L5) dermatome.
- B. Absence of the client's posterior tibial pulse.
- C. The client has a respiratory rate of eight (8).
- D. The blood pressure is within 20% of the client's baseline.
Correct Answer: C
Rationale: A respiratory rate of 8 suggests respiratory depression, a serious spinal anesthesia complication. L5 numbness is expected, absent pulse suggests vascular issues, and stable BP is normal.
Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure?
- A. The nurse should provide detailed information about the procedure.
- B. The nurse should inform the client of any legal consultation needed.
- C. The nurse should write a list of the risks for postoperative complications.
- D. The nurse should ensure the client is voluntarily giving consent.
Correct Answer: D
Rationale: The nurse ensures voluntary consent, verifying understanding and no coercion, per ethical standards. Detailed information, legal consultation, and risk lists are the HCP’s role.
The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement?
- A. Close the curtains around the client's stretcher.
- B. Instruct the UAP and scrub tech to stop the discussion.
- C. Tell the surgeon on the case what the nurse overheard.
- D. Inform the client the discussion was not about her surgeon.
Correct Answer: B
Rationale: Instructing the UAP and tech to stop protects patient privacy and reduces anxiety, per HIPAA. Curtains, informing the surgeon, or reassuring the client are less direct.