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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 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 has the highest priority when preparing the client for a surgical procedure?
- A. Pad the client's elbows and knees.
- B. Apply soft restraint straps to the extremities.
- C. Prepare the client's incision site.
- D. Document the temperature of the room.
Correct Answer: C
Rationale: Preparing the incision site ensures asepsis, reducing infection risk, the highest priority. Padding, restraints, and room temperature are secondary.
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
- A. Change the dressing over the surgical site.
- B. Teach the client how to perform incentive spirometry.
- C. Empty and record the amount of drainage in the JP drain.
- D. Auscultate the bowel sounds in all four (4) quadrants.
Correct Answer: C
Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.
The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first?
- A. Assess the client's breath sounds.
- B. Apply oxygen via nasal cannula.
- C. Take the client's blood pressure.
- D. Monitor the pulse oximeter reading.
Correct Answer: A
Rationale: Assessing breath sounds ensures airway patency and ventilation, the priority post-OR per ABCs. Oxygen, BP, and pulse oximetry follow airway assessment.
The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
- A. The client has loose, decayed teeth.
- B. The client is experiencing anxiety.
- C. The client smokes two (2) packs of cigarettes a day.
- D. The client has had a chest x-ray which does not show infiltrates.
- E. The client reports using herbs.
Correct Answer: A,C,E
Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.