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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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The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse?
- A. The 4-year-old client who had a tonsillectomy and is able to swallow fluids.
- B. The 74-year-old client with a repair of the left hip who is unable to ambulate.
- C. The 24-year-old client who had an uncomplicated appendectomy the previous day.
- D. The 80-year-old client with small bowel obstruction and congestive heart failure.
Correct Answer: D
Rationale: The 80-year-old with small bowel obstruction and CHF has complex needs (fluid balance, cardiac monitoring), requiring an experienced nurse. Tonsillectomy, hip repair, and appendectomy are less complex.
The client received naloxone (Narcan), an opioid antagonist, in the postanesthesia care unit. Which nursing intervention should the nurse include in the care plan?
- A. Measure the client's intake and output hourly.
- B. Administer sleep medications at night.
- C. Encourage the client to verbalize feelings.
- D. Monitor respirations every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression, requiring frequent respiratory monitoring to detect recurrence. I&O, sleep aids, and verbalization are secondary.
The nurse is preparing a client for surgery. Which intervention should the nurse implement first?
- A. Check the permit for the spouse's signature.
- B. Take and document intake and output.
- C. Administer the 'on call' sedative.
- D. Complete the preoperative checklist.
Correct Answer: D
Rationale: The preoperative checklist ensures all safety measures (e.g., consent, NPO, allergies) are verified, the first step. Spouse signature, I&O, and sedatives follow checklist completion.
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
- A. Insert an indwelling catheter.
- B. Increase the intravenous fluid rate.
- C. Assist the client to stand to void.
- D. Encourage the client to increase fluids.
Correct Answer: C
Rationale: Standing to void facilitates urination by using gravity, a non-invasive first step. Catheterization, IV fluids, and oral fluids are more invasive or 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.