Nokea
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
- A. Calcium 9.2 mg/dL.
- B. Bleeding time two (2) minutes.
- C. Hemoglobin 15 g/dL.
- D. Potassium 2.4 mEq/L.
Correct Answer: D
Rationale: Hypokalemia (2.4 mEq/L, normal 3.5–5.0) risks arrhythmias during anesthesia, requiring immediate intervention. Normal calcium, bleeding time, and hemoglobin are safe.
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Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority?
- A. Assess the client's respiratory status.
- B. Monitor the client's urinary output.
- C. Take a 12-lead ECG prior to injection.
- D. Attempt to keep the client focused.
Correct Answer: A
Rationale: Procedural sedation risks respiratory depression; assessing respiratory status is critical for safety. Urinary output, ECG, and focus are secondary.
The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8°F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement?
- A. Administer the antibiotic earlier than scheduled.
- B. Change the dressing over the wound.
- C. Have the client turn, cough, and deep breathe every two (2) hours.
- D. Encourage the client to ambulate in the hall.
Correct Answer: C
Rationale: A low-grade fever (100.8°F) and tachypnea (R 24) suggest atelectasis; turning, coughing, and deep breathing prevent respiratory complications. Antibiotics, dressing changes, and ambulation are secondary.
Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
- A. I will take my temperature each week and report any elevation.
- B. I will not need any pain medication when I go home.
- C. I will take all of my antibiotics until they are gone.
- D. I will not take a shower until my three (3)-month checkup.
Correct Answer: C
Rationale: Completing antibiotics prevents infection, a key teaching point. Weekly temperature checks are excessive, pain medication is often needed, and showering is allowed sooner.
The client in the surgical holding area tells the nurse 'I am so scared. I have never had surgery before.' Which statement would be the most appropriate response?
- A. Why are you afraid of the surgery?
- B. This is the best hospital in the city.
- C. Does having surgery make you afraid?
- D. There is no reason to be afraid.
Correct Answer: C
Rationale: Reflecting the client’s fear validates feelings, encouraging discussion. Asking 'why,' boasting about the hospital, or dismissing fear is less therapeutic.