Nokea
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.
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The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
- A. Notify the surgeon the client has had an evisceration.
- B. Contact the surgery department to prepare for emergency surgery.
- C. Assess the operative site and cover the site with a moistened dressing.
- D. Explain this is a common feeling and tell the client to continue with activity.
Correct Answer: C
Rationale: A popping sound and opening sensation suggest dehiscence or evisceration; assessing and covering with a moist dressing stabilizes the site, the first step. Notification and surgery prep follow, and dismissing the symptom is unsafe.
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 completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon?
- A. The client understands the purpose of the surgery.
- B. The client stopped taking aspirin three (3) weeks ago.
- C. The client uses the oral supplements licorice and garlic.
- D. The client has mild levels of preoperative anxiety.
Correct Answer: C
Rationale: Licorice and garlic may increase bleeding risk or interact with anesthesia, requiring surgeon notification. Understanding, aspirin cessation, and mild anxiety are expected or safe.
The client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6°F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.
- A. Increase the IV rate.
- B. Notify the health-care provider.
- C. Elevate the foot of the bed.
- D. Check the abdominal dressing.
- E. Determine if the IV antibiotics have been administered.
Correct Answer: C,A,B,D,E
Rationale: 1) Elevate foot of bed (Trendelenburg for hypotension); 2) Notify HCP (fever, tachycardia, hypotension suggest sepsis); 3) Increase IV rate (bolus for hypovolemia); 4) Check dressing (assess bleeding); 5) Confirm antibiotics (treat infection).
The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Perform passive range-of-motion exercises.
- B. Discuss how to cough and deep breathe effectively.
- C. Tell the client he can have a meal in the PACU.
- D. Teach ways to manage postoperative pain.
- E. Discuss events which occur in the postanesthesia care unit.
Correct Answer: B,D,E
Rationale: Coughing/deep breathing prevents atelectasis, pain management enhances recovery, and PACU education reduces anxiety. Passive ROM is postoperative, and meals are not allowed in PACU.