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The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8°F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement?
- A. Administer the antibiotic earlier than scheduled.
- B. Change the dressing over the wound.
- C. Have the client turn, cough, and deep breathe every two (2) hours.
- D. Encourage the client to ambulate in the hall.
Correct Answer: C
Rationale: A low-grade fever (100.8°F) and tachypnea (R 24) suggest atelectasis; turning, coughing, and deep breathing prevent respiratory complications. Antibiotics, dressing changes, and ambulation are secondary.
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The nurse is preparing a client for surgery. Which intervention should the nurse implement first?
- A. Check the permit for the spouse's signature.
- B. Take and document intake and output.
- C. Administer the 'on call' sedative.
- D. Complete the preoperative checklist.
Correct Answer: D
Rationale: The preoperative checklist ensures all safety measures (e.g., consent, NPO, allergies) are verified, the first step. Spouse signature, I&O, and sedatives follow checklist completion.
The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority?
- A. Assess the client's respiratory status.
- B. Monitor the client's urinary output.
- C. Take a 12-lead ECG prior to injection.
- D. Attempt to keep the client focused.
Correct Answer: A
Rationale: Procedural sedation risks respiratory depression; assessing respiratory status is critical for safety. Urinary output, ECG, and focus are secondary.
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
- A. Calcium 9.2 mg/dL.
- B. Bleeding time two (2) minutes.
- C. Hemoglobin 15 g/dL.
- D. Potassium 2.4 mEq/L.
Correct Answer: D
Rationale: Hypokalemia (2.4 mEq/L, normal 3.5–5.0) risks arrhythmias during anesthesia, requiring immediate intervention. Normal calcium, bleeding time, and hemoglobin are safe.
The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse?
- A. The 4-year-old client who had a tonsillectomy and is able to swallow fluids.
- B. The 74-year-old client with a repair of the left hip who is unable to ambulate.
- C. The 24-year-old client who had an uncomplicated appendectomy the previous day.
- D. The 80-year-old client with small bowel obstruction and congestive heart failure.
Correct Answer: D
Rationale: The 80-year-old with small bowel obstruction and CHF has complex needs (fluid balance, cardiac monitoring), requiring an experienced nurse. Tonsillectomy, hip repair, and appendectomy are less complex.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.