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Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.
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Which client would the nurse identify as having the highest risk for developing postoperative complications?
- A. The 67-year-old client who is obese, has diabetes, and takes insulin.
- B. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
- C. The 45-year-old client having abdominal surgery to remove the gallbladder.
- D. The 60-year-old client with anemia who smokes one (1) pack of cigarettes a day.
Correct Answer: A
Rationale: Obesity, diabetes, and insulin use increase risks for infection, poor wound healing, and glycemic instability, the highest risk profile. Arthritis, cholecystectomy, and anemia/smoking are less severe.
The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome?
- A. The client has no injuries from the OR equipment.
- B. The client has no postoperative infection.
- C. The client has stable vital signs during surgery.
- D. The client recovers from anesthesia.
Correct Answer: A
Rationale: The circulating nurse’s role focuses on preventing equipment-related injuries (e.g., burns, pressure sores) intraoperatively. Infection, vital signs, and recovery are broader concerns.
Which statement should the nurse identify as the expected outcome for a client experiencing acute pain?
- A. The client will have decreased use of medication.
- B. The client will participate in self-care activities.
- C. The client will use relaxation techniques.
- D. The client will repeat instructions about medications.
Correct Answer: B
Rationale: Participating in self-care indicates effective pain control, enabling function, the primary outcome. Medication reduction, relaxation, and instruction repetition are secondary.
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.
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.