Nokea
The three (3)-day postoperative client is complaining of unrelieved pain at the incision site one (1) hour after the administration of narcotic pain medication. Which action should the nurse implement first?
- A. Check the MAR for another medication to administer.
- B. Teach the client to use guided imagery to relieve the pain.
- C. Assess the client for complications.
- D. Elevate the head of the client's bed.
Correct Answer: C
Rationale: Unrelieved pain post-narcotic may indicate complications (e.g., infection, hematoma), requiring assessment first. Additional medication, imagery, or HOB elevation follow.
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The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement?
- A. Determine why the client is not using the PCA pump.
- B. Document the amount and take no action.
- C. Chart the client is not having pain.
- D. Contact the HCP and request oral medication.
Correct Answer: A
Rationale: Determining why the client underuses the PCA (e.g., misunderstanding, side effects) ensures effective pain management. Documentation alone, assuming no pain, or changing medication is premature.
The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery?
- A. The 65-year-old client who cannot read or write.
- B. The 30-year-old client who does not understand English.
- C. The 16-year-old client who has a fractured ankle.
- D. The 80-year-old client who is not oriented to the day.
Correct Answer: D
Rationale: Legal consent requires mental competency; disorientation to the day suggests incapacity. Illiteracy, language barriers (with interpreters), and minors (with parental consent) do not preclude consent.
Which problem should the nurse identify as priority for client who is one (1) day postoperative?
- A. Potential for hemorrhaging.
- B. Potential for injury.
- C. Potential for fluid volume excess.
- D. Potential for infection.
Correct Answer: A
Rationale: Hemorrhaging is a life-threatening risk in the first 24–48 hours post-surgery, the priority. Injury, fluid excess, and infection are secondary.
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.
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.