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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 nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
- A. The client has loose, decayed teeth.
- B. The client is experiencing anxiety.
- C. The client smokes two (2) packs of cigarettes a day.
- D. The client has had a chest x-ray which does not show infiltrates.
- E. The client reports using herbs.
Correct Answer: A,C,E
Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.
Which activities are the circulating nurse's responsibilities in the operating room?
- A. Monitor the position of the client, prepare the surgical site, and ensure the client's safety.
- B. Give preoperative medication in the holding area and monitor the client's response to anesthesia.
- C. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments.
- D. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.
Correct Answer: A
Rationale: The circulating nurse monitors positioning, preps the site, and ensures safety, maintaining a non-sterile role. Medications, sterile field setup, and anesthesia tubing are other roles.
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
- A. Change the dressing over the surgical site.
- B. Teach the client how to perform incentive spirometry.
- C. Empty and record the amount of drainage in the JP drain.
- D. Auscultate the bowel sounds in all four (4) quadrants.
Correct Answer: C
Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.
The client is complaining of left shoulder pain. Which intervention should the nurse implement first?
- A. Assess the neurovascular status of the left hand.
- B. Check the medication administration record (MAR).
- C. Ask if the client wants pain medication.
- D. Administer the client's pain medication.
Correct Answer: A
Rationale: Assessing neurovascular status rules out referred pain from cardiac or vascular issues, the priority per ABCs. MAR checks, asking about medication, and administration follow.
Which nursing intervention is priority for the client experiencing acute pain?
- A. Assess the client's verbal and nonverbal behavior.
- B. Wait for the client to request pain medication.
- C. Administer the pain medication on a scheduled basis.
- D. Teach the client to use only imagery every hour for the pain.
Correct Answer: A
Rationale: Assessing verbal and nonverbal behavior determines pain severity and guides treatment, the priority. Waiting, scheduled dosing, or imagery alone delays or limits care.