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Which situation demonstrates the circulating nurse acting as the client's advocate?
- A. Plays the client's favorite audio book during surgery.
- B. Keeps the family informed of the findings of the surgery.
- C. Keeps the operating room door closed at all times.
- D. Calls the client by the first name when the client is recovering.
Correct Answer: C
Rationale: Keeping the OR door closed maintains privacy and asepsis, advocating for client safety. Audio books, family updates, and name use are supportive but less critical.
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The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement?
- A. Determine why the client is not using the PCA pump.
- B. Document the amount and take no action.
- C. Chart the client is not having pain.
- D. Contact the HCP and request oral medication.
Correct Answer: A
Rationale: Determining why the client underuses the PCA (e.g., misunderstanding, side effects) ensures effective pain management. Documentation alone, assuming no pain, or changing medication is premature.
The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
- A. Prepare ice packs and mix dantrolene sodium.
- B. Request the defibrillator be brought into the OR.
- C. Draw a PTT and prepare a heparin drip.
- D. Obtain finger stick blood glucose immediately.
Correct Answer: B
Rationale: Tachycardia and hypotension suggest shock or arrhythmia, requiring a defibrillator for potential cardioversion. Dantrolene is for malignant hyperthermia, heparin for clotting, and glucose is unrelated.
The nurse is completing a preoperative assessment on a male client who states, 'I am allergic to codeine.' Which intervention should the nurse implement first?
- A. Apply an allergy bracelet on the client's wrist.
- B. Label the client's allergies on the front of the chart.
- C. Ask the client what happens when he takes the codeine.
- D. Document the allergy on the medication administration record.
Correct Answer: C
Rationale: Asking about the reaction verifies the allergy type (e.g., anaphylaxis vs. nausea), guiding safe care. Bracelet, labeling, and documentation follow verification.
The client one (1) day postoperative develops an elevated temperature. Which intervention would have priority for the client?
- A. Encourage the client to deep breathe and cough every hour.
- B. Encourage the client to drink 200 mL of water every shift.
- C. Monitor the client's wound for drainage every eight (8) hours.
- D. Assess the urine output for color and clarity every four (4) hours.
Correct Answer: A
Rationale: Fever post-surgery often stems from atelectasis; deep breathing and coughing prevent respiratory complications, the priority. Hydration, wound monitoring, and urine assessment are secondary.
The surgical client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first?
- A. Call the surgeon and report the vital signs.
- B. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr.
- C. Elevate the feet and lower the head.
- D. Monitor the vital signs every 15 minutes.
Correct Answer: C
Rationale: Tachycardia, hypotension, and pale, damp skin suggest hypovolemic shock; Trendelenburg position (feet elevated, head lowered) improves cerebral perfusion, the first intervention. Surgeon notification, IV fluids, and monitoring follow.