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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.
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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 observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?
- A. Place the sponge back where it was.
- B. Tell the technician not to waste supplies.
- C. Do nothing because this is the correct procedure.
- D. Take the sponge out of the room immediately.
Correct Answer: C
Rationale: Removing a potentially contaminated sponge from the sterile field edge is correct to maintain asepsis. Replacing, criticizing, or removing it immediately is incorrect.
Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected?
- A. Urine output was 160 mL in the past eight (8) hours.
- B. Paralysis and paresthesia of the right leg.
- C. T 99.0°F, P 98, R 20, and BP 100/60.
- D. Lungs are clear bilaterally in all lobes.
Correct Answer: D
Rationale: Clear lungs indicate no respiratory complications, expected post-hip replacement. Low urine output (20 mL/hr), paralysis/paresthesia, and mild hypotension suggest complications.
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement?
- A. Administer pain medication as soon as the time frame allows.
- B. Use nonpharmacological methods to replace medications.
- C. Use cryotherapy after heat therapy because it works faster.
- D. Instruct family members to administer medication with the PCA.
Correct Answer: A
Rationale: Administering pain medication PRN within time frames ensures timely relief, per pain management standards. Nonpharmacological methods supplement, cryotherapy timing varies, and family PCA use is unsafe.
The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse?
- A. The client having open-heart surgery.
- B. The client having a biopsy of the breast.
- C. The client having laser eye surgery.
- D. The client having a laparoscopic knee repair.
Correct Answer: B
Rationale: Breast biopsy is a straightforward, low-risk procedure suitable for an inexperienced nurse. Open-heart, laser eye, and laparoscopic surgeries require advanced skills.