Nokea
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
- A. The client will be able to sit in the chair for 30 minutes.
- B. The client will have a pulse oximetry reading of 97% on room air.
- C. The client will have a urine output of 30 mL per hour.
- D. The client will be able to distinguish sharp from dull sensations.
Correct Answer: B
Rationale: A pulse oximetry of 97% on room air indicates adequate oxygenation post-general anesthesia, a key outcome. Sitting, urine output, and sensation are secondary or unrelated.
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The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
- A. The client has loose, decayed teeth.
- B. The client is experiencing anxiety.
- C. The client smokes two (2) packs of cigarettes a day.
- D. The client has had a chest x-ray which does not show infiltrates.
- E. The client reports using herbs.
Correct Answer: A,C,E
Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a surgery unit. Which task would be most appropriate to delegate to the UAP?
- A. Explain to the client how to cough and deep breathe.
- B. Discuss preoperative plans with the client and family.
- C. Determine the ability of the caregivers to provide postoperative care.
- D. Assist the client to take a povidone-iodine (Betadine) shower.
Correct Answer: D
Rationale: Assisting with a Betadine shower is a non-invasive task within UAP scope. Teaching, discussing plans, and assessing caregivers require nursing judgment.
The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed?
- A. I will be glad when this is over so I can go home today.
- B. I will not be able to eat or drink anything prior to my surgery.
- C. I can practice relaxing by listening to my favorite music.
- D. I will need to get up and walk as soon as possible.
Correct Answer: A
Rationale: Emergency appendectomy requires postoperative recovery, typically 1–2 days in hospital, so expecting to go home today indicates misunderstanding. NPO status, relaxation, and early ambulation are correct.
The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
- A. Increase the intravenous fluids.
- B. Lower one leg at a time.
- C. Raise the foot of the stretcher.
- D. Administer epinephrine, a vasopressor.
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
- A. Change the dressing over the surgical site.
- B. Teach the client how to perform incentive spirometry.
- C. Empty and record the amount of drainage in the JP drain.
- D. Auscultate the bowel sounds in all four (4) quadrants.
Correct Answer: C
Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.