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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.
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Which client would the nurse identify as having the highest risk for developing postoperative complications?
- A. The 67-year-old client who is obese, has diabetes, and takes insulin.
- B. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
- C. The 45-year-old client having abdominal surgery to remove the gallbladder.
- D. The 60-year-old client with anemia who smokes one (1) pack of cigarettes a day.
Correct Answer: A
Rationale: Obesity, diabetes, and insulin use increase risks for infection, poor wound healing, and glycemic instability, the highest risk profile. Arthritis, cholecystectomy, and anemia/smoking are less severe.
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.
Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
- A. Calcium 9.2 mg/dL.
- B. Bleeding time two (2) minutes.
- C. Hemoglobin 15 g/dL.
- D. Potassium 2.4 mEq/L.
Correct Answer: D
Rationale: Hypokalemia (2.4 mEq/L, normal 3.5–5.0) risks arrhythmias during anesthesia, requiring immediate intervention. Normal calcium, bleeding time, and hemoglobin are safe.
The nurse is preparing a client for surgery. Which intervention should the nurse implement first?
- A. Check the permit for the spouse's signature.
- B. Take and document intake and output.
- C. Administer the 'on call' sedative.
- D. Complete the preoperative checklist.
Correct Answer: D
Rationale: The preoperative checklist ensures all safety measures (e.g., consent, NPO, allergies) are verified, the first step. Spouse signature, I&O, and sedatives follow checklist completion.