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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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Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Complete the preoperative checklist.
- B. Assess the client's preoperative vital signs.
- C. Teach the client about coughing and deep breathing.
- D. Assist the client to remove clothing and jewelry.
Correct Answer: D
Rationale: Removing clothing and jewelry is a non-invasive task within UAP scope. Checklist completion, vital signs, and teaching require nursing judgment.
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 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.
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain?
- A. Take the pain medication to the room.
- B. Apply an ice pack to the site of pain.
- C. Check on the client 30 minutes after she takes the pain medication.
- D. Observe the client's ability to use the PCA.
Correct Answer: B
Rationale: Applying an ice pack is a non-invasive task within UAP scope. Delivering medication, post-medication checks, and PCA observation require nursing judgment.
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.