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Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure?
- A. The nurse should provide detailed information about the procedure.
- B. The nurse should inform the client of any legal consultation needed.
- C. The nurse should write a list of the risks for postoperative complications.
- D. The nurse should ensure the client is voluntarily giving consent.
Correct Answer: D
Rationale: The nurse ensures voluntary consent, verifying understanding and no coercion, per ethical standards. Detailed information, legal consultation, and risk lists are the HCP’s role.
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The circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first?
- A. Include the sponge in the sponge count.
- B. Obtain a new sterile instrument pack.
- C. Tell the surgical technologist about the sponge.
- D. Throw the sponge in the sterile trashcan.
Correct Answer: C
Rationale: Telling the technologist ensures the contaminated sponge is removed from the sterile field, maintaining asepsis. Counting, new instruments, or trashing are secondary or incorrect.
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
- A. Loss of sensation at the lumbar (L5) dermatome.
- B. Absence of the client's posterior tibial pulse.
- C. The client has a respiratory rate of eight (8).
- D. The blood pressure is within 20% of the client's baseline.
Correct Answer: C
Rationale: A respiratory rate of 8 suggests respiratory depression, a serious spinal anesthesia complication. L5 numbness is expected, absent pulse suggests vascular issues, and stable BP is normal.
The client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? Select all that apply.
- A. Review the client's chart.
- B. Notify the surgeon.
- C. Immediately call a 'time-out.'
- D. Correct the surgical permit.
- E. Request the client mark the left arm.
Correct Answer: A,B,C
Rationale: Reviewing the chart verifies the correct site, notifying the surgeon addresses the discrepancy, and calling a time-out ensures team confirmation. Correcting the permit or marking the wrong site is unsafe.
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain?
- A. Take the pain medication to the room.
- B. Apply an ice pack to the site of pain.
- C. Check on the client 30 minutes after she takes the pain medication.
- D. Observe the client's ability to use the PCA.
Correct Answer: B
Rationale: Applying an ice pack is a non-invasive task within UAP scope. Delivering medication, post-medication checks, and PCA observation require nursing judgment.
The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement?
- A. Close the curtains around the client's stretcher.
- B. Instruct the UAP and scrub tech to stop the discussion.
- C. Tell the surgeon on the case what the nurse overheard.
- D. Inform the client the discussion was not about her surgeon.
Correct Answer: B
Rationale: Instructing the UAP and tech to stop protects patient privacy and reduces anxiety, per HIPAA. Curtains, informing the surgeon, or reassuring the client are less direct.