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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 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.
Which intervention has priority for the nurse in the surgical holding area?
- A. Verify the surgical checklist.
- B. Prepare the client's surgical site.
- C. Assist the client to the bathroom.
- D. Restrain the client on the surgery table.
Correct Answer: A
Rationale: Verifying the surgical checklist ensures safety (e.g., site, consent), the priority in the holding area. Site prep, bathroom assistance, and restraints are secondary or intraoperative.
The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
- A. Prepare ice packs and mix dantrolene sodium.
- B. Request the defibrillator be brought into the OR.
- C. Draw a PTT and prepare a heparin drip.
- D. Obtain finger stick blood glucose immediately.
Correct Answer: B
Rationale: Tachycardia and hypotension suggest shock or arrhythmia, requiring a defibrillator for potential cardioversion. Dantrolene is for malignant hyperthermia, heparin for clotting, and glucose is unrelated.
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.
Which situation is an example of the nurse fulfilling the role of client advocate?
- A. The nurse brings the client pain medication when it is due.
- B. The nurse collaborates with other disciplines during the care conference.
- C. The nurse contacts the health-care provider when pain relief is not obtained.
- D. The nurse teaches the client to ask for medication before the pain gets to a '5.'
Correct Answer: C
Rationale: Contacting the HCP for inadequate pain relief advocates for the client’s comfort. Bringing medication, collaborating, and teaching are supportive but less advocacy-focused.