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Which activities are the circulating nurse's responsibilities in the operating room?
- A. Monitor the position of the client, prepare the surgical site, and ensure the client's safety.
- B. Give preoperative medication in the holding area and monitor the client's response to anesthesia.
- C. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments.
- D. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.
Correct Answer: A
Rationale: The circulating nurse monitors positioning, preps the site, and ensures safety, maintaining a non-sterile role. Medications, sterile field setup, and anesthesia tubing are other roles.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a surgery unit. Which task would be most appropriate to delegate to the UAP?
- A. Explain to the client how to cough and deep breathe.
- B. Discuss preoperative plans with the client and family.
- C. Determine the ability of the caregivers to provide postoperative care.
- D. Assist the client to take a povidone-iodine (Betadine) shower.
Correct Answer: D
Rationale: Assisting with a Betadine shower is a non-invasive task within UAP scope. Teaching, discussing plans, and assessing caregivers require nursing judgment.
The nurse identifies the nursing diagnosis 'risk for injury related to positioning' for the client in the operating room. Which nursing intervention should the nurse implement?
- A. Avoid using the cautery unit which does not have a biomedical tag on it.
- B. Carefully pad the client's elbows before covering the client with a blanket.
- C. Apply a warming pad on the OR table before placing the client on the table.
- D. Check the chart for any prescription or over-the-counter medication use.
Correct Answer: B
Rationale: Padding elbows prevents pressure injuries during positioning, addressing the diagnosis. Cautery, warming pads, and medication checks are unrelated to positioning.
Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain?
- A. Monitor the client's vital signs.
- B. Verify the time of the last dose.
- C. Check for the client's allergies.
- D. Discuss the pain with the client.
Correct Answer: C
Rationale: Checking allergies prevents adverse reactions, the highest safety priority. Vital signs, timing, and pain discussion follow.
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
- A. The client will be able to sit in the chair for 30 minutes.
- B. The client will have a pulse oximetry reading of 97% on room air.
- C. The client will have a urine output of 30 mL per hour.
- D. The client will be able to distinguish sharp from dull sensations.
Correct Answer: B
Rationale: A pulse oximetry of 97% on room air indicates adequate oxygenation post-general anesthesia, a key outcome. Sitting, urine output, and sensation are secondary or unrelated.
The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Perform passive range-of-motion exercises.
- B. Discuss how to cough and deep breathe effectively.
- C. Tell the client he can have a meal in the PACU.
- D. Teach ways to manage postoperative pain.
- E. Discuss events which occur in the postanesthesia care unit.
Correct Answer: B,D,E
Rationale: Coughing/deep breathing prevents atelectasis, pain management enhances recovery, and PACU education reduces anxiety. Passive ROM is postoperative, and meals are not allowed in PACU.