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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.
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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.
The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
- A. Increase the intravenous fluids.
- B. Lower one leg at a time.
- C. Raise the foot of the stretcher.
- D. Administer epinephrine, a vasopressor.
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
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.
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
- A. The client will be able to sit in the chair for 30 minutes.
- B. The client will have a pulse oximetry reading of 97% on room air.
- C. The client will have a urine output of 30 mL per hour.
- D. The client will be able to distinguish sharp from dull sensations.
Correct Answer: B
Rationale: A pulse oximetry of 97% on room air indicates adequate oxygenation post-general anesthesia, a key outcome. Sitting, urine output, and sensation are secondary or unrelated.
The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first?
- A. Inform the other members of the surgical team about the problem.
- B. Assume the original count was wrong and change the record.
- C. Call the radiology department to perform a portable x-ray.
- D. Complete an occurrence report and notify the risk manager.
Correct Answer: A
Rationale: Informing the team prompts a recount and investigation, the first step to prevent retained needles. Assuming errors, ordering x-rays, or reporting are premature.