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Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
- A. I will take my temperature each week and report any elevation.
- B. I will not need any pain medication when I go home.
- C. I will take all of my antibiotics until they are gone.
- D. I will not take a shower until my three (3)-month checkup.
Correct Answer: C
Rationale: Completing antibiotics prevents infection, a key teaching point. Weekly temperature checks are excessive, pain medication is often needed, and showering is allowed sooner.
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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.
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 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first?
- A. Notify the surgeon of the client's status.
- B. Continue giving enemas until clear.
- C. Increase the client's IV fluid rate.
- D. Obtain STAT serum electrolytes.
Correct Answer: A
Rationale: Notifying the surgeon ensures guidance on proceeding, as unclear returns may indicate obstruction or inadequate prep, risking complications. More enemas, IV fluids, or electrolytes are secondary.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
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.