Nokea
The surgical client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first?
- A. Call the surgeon and report the vital signs.
- B. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr.
- C. Elevate the feet and lower the head.
- D. Monitor the vital signs every 15 minutes.
Correct Answer: C
Rationale: Tachycardia, hypotension, and pale, damp skin suggest hypovolemic shock; Trendelenburg position (feet elevated, head lowered) improves cerebral perfusion, the first intervention. Surgeon notification, IV fluids, and monitoring follow.
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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.
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 assessing a client in the day surgery unit who states, 'I am really afraid of having this surgery. I'm afraid of what they will find.' Which statement would be the most therapeutic response by the nurse?
- A. Don't worry about your surgery. It is safe.
- B. Tell me why you're worried about your surgery.
- C. Tell me about your fears of having this surgery.
- D. I understand how you feel. Surgery is frightening.
Correct Answer: C
Rationale: Asking about fears encourages the client to express concerns, fostering therapeutic communication. Reassurance, asking 'why,' or assuming feelings are less empathetic.
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.
Which client outcome would the nurse identify for the preoperative client?
- A. The client's abnormal laboratory data will be reported to the anesthesiologist.
- B. The client will not have any postoperative complications for the first 24 hours.
- C. The client will demonstrate the use of a pillow to splint while deep breathing.
- D. The client will complete an advance directive before having the surgery.
Correct Answer: C
Rationale: Demonstrating pillow splinting for deep breathing prepares the client to prevent atelectasis, a measurable preoperative outcome. Lab reporting, complication-free periods, and advance directives are not client actions.