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Which situation is an example of the nurse fulfilling the role of client advocate?
- A. The nurse brings the client pain medication when it is due.
- B. The nurse collaborates with other disciplines during the care conference.
- C. The nurse contacts the health-care provider when pain relief is not obtained.
- D. The nurse teaches the client to ask for medication before the pain gets to a '5.'
Correct Answer: C
Rationale: Contacting the HCP for inadequate pain relief advocates for the client’s comfort. Bringing medication, collaborating, and teaching are supportive but less advocacy-focused.
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The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP?
- A. Take routine vital signs on clients.
- B. Check the Jackson Pratt insertion site.
- C. Hang the client's next IV bag.
- D. Ensure the client obtains pain relief.
Correct Answer: A
Rationale: Taking vital signs is within UAP scope. Checking drains, hanging IVs, and ensuring pain relief require nursing assessment or licensure.
The nurse received a male client from the postanesthesia care unit. Which assessment data would warrant immediate intervention?
- A. The client's vital signs are T 97°F, P 108, R 24, and BP 80/40.
- B. The client is sleepy but opens the eyes to his name.
- C. The client is complaining of pain at a '5' on a 1-to-10 pain scale.
- D. The client has 20 mL of urine in the urinary drainage bag.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (80/40) suggest hypovolemic shock, requiring immediate intervention. Sleepiness, moderate pain, and low urine output are less urgent.
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 and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first?
- A. Notify the client's surgeon.
- B. Complete an occurrence report.
- C. Contact the surgical manager.
- D. Recount all sponges.
Correct Answer: D
Rationale: Recounting sponges verifies the discrepancy, the first step to ensure no retained objects. Notification, reporting, or manager contact follow if confirmed.
Which client assessment data are priority for the postanesthesia care nurse?
- A. Bowel sounds.
- B. Vital signs.
- C. IV fluid rate.
- D. Surgical site.
Correct Answer: B
Rationale: Vital signs are the priority in PACU to monitor stability per ABCs. Bowel sounds, IV rate, and surgical site are secondary.