Nokea
Which action by the client indicates to the nurse preoperative teaching has been effective?
- A. The client demonstrates how to use the incentive spirometer device.
- B. The client demonstrates the use of the patient-controlled analgesia pump.
- C. The client can name two (2) anesthesia agents used during surgery.
- D. The client ambulates down the hall to the nurse's station each hour.
Correct Answer: A
Rationale: Using the incentive spirometer correctly prevents atelectasis, a key preoperative teaching goal. PCA use is postoperative, naming agents is unnecessary, and hourly ambulation is excessive.
You may also like to solve these questions
The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management?
- A. Have you ever had difficulty getting your pain controlled?
- B. What types of surgery have you had in the last 10 years?
- C. Have you ever been addicted to narcotics?
- D. Do you have a list of your prescription medications?
Correct Answer: A
Rationale: Asking about past pain control identifies effective strategies or barriers, guiding management. Surgical history, addiction, and medication lists are secondary.
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 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.
The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care?
- A. Risk for injury.
- B. Altered comfort level.
- C. Impaired circulation.
- D. Impaired skin integrity.
Correct Answer: A
Rationale: Confusion increases fall and injury risk, the priority problem in elderly postoperative clients. Comfort, circulation, and skin integrity are secondary.
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.