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Which client outcome would the nurse identify for the preoperative client?
- A. The client's abnormal laboratory data will be reported to the anesthesiologist.
- B. The client will not have any postoperative complications for the first 24 hours.
- C. The client will demonstrate the use of a pillow to splint while deep breathing.
- D. The client will complete an advance directive before having the surgery.
Correct Answer: C
Rationale: Demonstrating pillow splinting for deep breathing prepares the client to prevent atelectasis, a measurable preoperative outcome. Lab reporting, complication-free periods, and advance directives are not client actions.
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The nurse is assessing a client in the day surgery unit who states, 'I am really afraid of having this surgery. I'm afraid of what they will find.' Which statement would be the most therapeutic response by the nurse?
- A. Don't worry about your surgery. It is safe.
- B. Tell me why you're worried about your surgery.
- C. Tell me about your fears of having this surgery.
- D. I understand how you feel. Surgery is frightening.
Correct Answer: C
Rationale: Asking about fears encourages the client to express concerns, fostering therapeutic communication. Reassurance, asking 'why,' or assuming feelings are less empathetic.
The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement?
- A. Determine why the client is not using the PCA pump.
- B. Document the amount and take no action.
- C. Chart the client is not having pain.
- D. Contact the HCP and request oral medication.
Correct Answer: A
Rationale: Determining why the client underuses the PCA (e.g., misunderstanding, side effects) ensures effective pain management. Documentation alone, assuming no pain, or changing medication is premature.
The three (3)-day postoperative client is complaining of unrelieved pain at the incision site one (1) hour after the administration of narcotic pain medication. Which action should the nurse implement first?
- A. Check the MAR for another medication to administer.
- B. Teach the client to use guided imagery to relieve the pain.
- C. Assess the client for complications.
- D. Elevate the head of the client's bed.
Correct Answer: C
Rationale: Unrelieved pain post-narcotic may indicate complications (e.g., infection, hematoma), requiring assessment first. Additional medication, imagery, or HOB elevation follow.
The surgical client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first?
- A. Call the surgeon and report the vital signs.
- B. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr.
- C. Elevate the feet and lower the head.
- D. Monitor the vital signs every 15 minutes.
Correct Answer: C
Rationale: Tachycardia, hypotension, and pale, damp skin suggest hypovolemic shock; Trendelenburg position (feet elevated, head lowered) improves cerebral perfusion, the first intervention. Surgeon notification, IV fluids, and monitoring follow.
The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? Select all that apply.
- A. Compare the hospital number on the MAR to the client's bracelet.
- B. Have a witness verify the wasted portion of the narcotic.
- C. Assess the client's vital signs prior to administration.
- D. Determine if the client has any allergies to medications.
- E. Clarify all pain medication orders with the health-care provider.
Correct Answer: A,B,C,D
Rationale: Verifying ID, witnessing waste, checking vital signs, and confirming allergies ensure opioid safety. Clarifying all orders is unnecessary unless unclear.