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Which statement should the nurse identify as the expected outcome for a client experiencing acute pain?
- A. The client will have decreased use of medication.
- B. The client will participate in self-care activities.
- C. The client will use relaxation techniques.
- D. The client will repeat instructions about medications.
Correct Answer: B
Rationale: Participating in self-care indicates effective pain control, enabling function, the primary outcome. Medication reduction, relaxation, and instruction repetition are secondary.
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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.
Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
- A. Surgical supplies were cleaned and sterilized prior to the case.
- B. The circulating nurse is wearing a long-sleeved sterile gown.
- C. Masks covering the mouth and nose are being worn by the surgical team.
- D. The scrub nurse setting up the sterile field is wearing artificial nails.
Correct Answer: D
Rationale: Artificial nails harbor bacteria, violating asepsis and risking infection, requiring immediate intervention. Sterilized supplies, masks, and long-sleeved gowns (if non-sterile role) are appropriate.
The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority?
- A. Assess the client's respiratory status.
- B. Monitor the client's urinary output.
- C. Take a 12-lead ECG prior to injection.
- D. Attempt to keep the client focused.
Correct Answer: A
Rationale: Procedural sedation risks respiratory depression; assessing respiratory status is critical for safety. Urinary output, ECG, and focus are secondary.
Which problem would be appropriate for the nurse to identify for the preoperative client having an open reduction and internal fixation of the right ankle?
- A. Alteration in skin integrity.
- B. Knowledge deficit of postoperative care.
- C. Alteration in gas exchange and pattern.
- D. Alteration in urinary elimination.
Correct Answer: B
Rationale: Knowledge deficit of postoperative care (e.g., weight-bearing, wound care) is common pre-ankle surgery, guiding teaching. Skin integrity, gas exchange, and urinary issues are postoperative or unrelated.
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.