Nokea
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.
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Which problem should the nurse identify as priority for client who is one (1) day postoperative?
- A. Potential for hemorrhaging.
- B. Potential for injury.
- C. Potential for fluid volume excess.
- D. Potential for infection.
Correct Answer: A
Rationale: Hemorrhaging is a life-threatening risk in the first 24–48 hours post-surgery, the priority. Injury, fluid excess, and infection are secondary.
The nurse received a male client from the postanesthesia care unit. Which assessment data would warrant immediate intervention?
- A. The client's vital signs are T 97°F, P 108, R 24, and BP 80/40.
- B. The client is sleepy but opens the eyes to his name.
- C. The client is complaining of pain at a '5' on a 1-to-10 pain scale.
- D. The client has 20 mL of urine in the urinary drainage bag.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (80/40) suggest hypovolemic shock, requiring immediate intervention. Sleepiness, moderate pain, and low urine output are less urgent.
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 nurse is completing a preoperative assessment on a male client who states, 'I am allergic to codeine.' Which intervention should the nurse implement first?
- A. Apply an allergy bracelet on the client's wrist.
- B. Label the client's allergies on the front of the chart.
- C. Ask the client what happens when he takes the codeine.
- D. Document the allergy on the medication administration record.
Correct Answer: C
Rationale: Asking about the reaction verifies the allergy type (e.g., anaphylaxis vs. nausea), guiding safe care. Bracelet, labeling, and documentation follow verification.
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.