Question

A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

Answer 1

Correct Answers:

Administer prescribed opioid analgesic

Rationale :

💊Pain rated 8/10 is considered severe and requires immediate intervention with prescribed opioid analgesics for effective relief.

🩺This action addresses the physiologic and emotional stress that can delay healing and increase complications.

🔄While repositioning or distraction techniques may help later, severe pain demands prompt pharmacologic management.

📈Effective pain relief promotes patient recovery, mobility, and respiratory function.

📌Core Message

Treat severe postoperative pain immediately using prescribed opioids to promote comfort and recovery.

Answer 2

Correct Answers:

Monitor the patient's respiratory rate and sedation level every 1 - 2 hours

Rationale :

👀Monitoring respiratory rate and sedation level is critical with PCA morphine due to the risk of respiratory depression.

📉This ensures early detection of oversedation, which can lead to hypoventilation or even respiratory arrest.

🚫Family members should never press the PCA button—this violates safety protocols and risks uncontrolled dosing.

🔧Only the provider should adjust PCA settings based on assessment.

📌Core Message

Regularly monitor respiratory status with PCA morphine to ensure safe and effective pain control.

Answer 3

Correct Answers:

Ensuring that informed consent has been signed and is in the medical record

Rationale :

✍️Informed consent is a legal and ethical requirement before surgery, and it is the nurse's role to verify that it is properly documented.

📋Without signed consent, no surgical procedure should proceed.

🧾Other actions like removing jewelry or taking vitals are important, but they do not take precedence over legal authorization.

⚖️Ensuring consent respects the patient’s autonomy and upholds professional standards.

📌Core Message

Verifying signed informed consent is the top priority before surgery to uphold legal and ethical standards.

Answer 4

Correct Answers:

Instruct the patient on the use of an incentive spirometer
Discuss the importance of early ambulation after surgery
Review pain management options, including use of patient controlled analgesic (PCA)

Rationale :

💨Incentive spirometry and 🧍‍♂️early ambulation prevent postoperative respiratory and circulatory complications like atelectasis or DVT.

🧽Pain management education, including PCA use, empowers the patient and promotes comfort and cooperation post-op.

💁‍♂️Avoiding deep breathing is incorrect; deep breathing is essential to prevent pulmonary complications.

🦿There are no 6-month restrictions after laparoscopic surgery—mobility typically resumes within days to weeks.

📌Core Message

Pre-op teaching must include early ambulation, lung expansion, and pain control methods to reduce surgical risks.

Answer 5

Correct Answers:

Redness, warmth, purulent drainage and fever of 101.8 degree F (38.8 degree C)

Rationale :

🔥Classic signs of wound infection include redness, warmth, swelling, purulent discharge, and fever >100.4°F (38°C).

🦠This constellation of symptoms suggests bacterial involvement and requires immediate attention.

🩹Mild swelling or serosanguinous drainage is expected in early healing, but purulence and fever are red flags.

🧾Prompt intervention prevents sepsis and further wound complications.

📌Core Message

Wound infection is suspected when there's fever, purulent drainage, and local inflammation requiring prompt action.

Answer 6

Correct Answers:

Improving surgical site identification and time-out procedures

Rationale :

🗂️The National Patient Safety Goals (NPSGs) aim to improve surgical safety by ensuring correct patient identity, procedure, and site.

⏱️Time-outs are a critical pause where the team verifies all identifiers before starting surgery.

💰Operational cost or advertising has no clinical relevance to NPSG goals.

😊Patient satisfaction is valued but is not the core safety focus of the program.

📌Core Message

The National Patient Safety Goals emphasize site verification and time-out procedures to prevent surgical errors.

Answer 7

Correct Answers:

The client now has a fever of 100.4 degrees
Patient is complaining of chest pain now

Rationale :

🌡️A fever of 100.4°F (38°C) may indicate a developing infection, which should be reported before surgery.

💔New chest pain could suggest a cardiac event or pulmonary issue, and surgery should be delayed pending evaluation.

😟Anxiety is expected and doesn’t typically warrant provider notification unless it’s severe or interfering with preparation.

📉Stable vitals like BP 120/80 and HR 76 are normal and do not require reporting.

📌Core Message

New fever or chest pain before surgery requires immediate provider notification to prevent perioperative risks.

Answer 8

Correct Answers:

Empty and compress the drain bulb when it is half full or every 8 hours, using sterile technique

Rationale :

💁‍♂️Jackson-Pratt drains rely on gentle suction, which is maintained by compressing the bulb after emptying.

🧼Sterile technique prevents infection, and emptying should occur when the bulb is half full or at regular intervals.

🌬️Keeping the bulb expanded defeats the purpose of suction.

🛑The nurse cannot remove the drain without a provider order, and clamping is generally discouraged due to backflow risk.

📌Core Message

JP drain function depends on regular emptying, compression, and sterile technique to prevent infection and blockage.

Answer 9

Correct Answers:

Monitoring for signs of hemorrhage

Rationale :

🩸In the first hour post-op, the top priority is to detect hemorrhage, which is the most life-threatening complication.

🧾Assessments for drain output, blood pressure, heart rate, and surgical site are critical.

💤Pain and bowel sounds can be assessed later, and while deep breathing is important, it does not take precedence over circulatory status.

🚨Early signs of bleeding can be subtle, so vigilant monitoring is essential.

📌Core Message

In the first hour post-op, prioritize hemorrhage monitoring to catch life-threatening blood loss early.

Answer 10

Correct Answers:

Immediately assess the surgical site for signs of wound dehiscence or evisceration

Rationale :

💥A "popping" sound with increased pain after coughing could indicate wound dehiscence or evisceration, which is a surgical emergency.

👀The nurse must immediately assess the site to determine the extent of separation and take emergency precautions.

🧼Actions like giving pain meds or documenting come after the initial assessment.

🔍Ignoring this could delay life-saving intervention.

📌Core Message

A sudden popping sound with pain after surgery signals possible wound dehiscence, requiring immediate site assessment.

NUR 105 Eve A Exam-1

No.

1 :
A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

2 :
A nurse is caring for a postoperative patient who is using a patient-controlled analgesia (PCA) [ump with morphine]. Which of the following nursing interventions is the most appropriate to ensure safe and effective pain management?

3 :
A nurse is caring for a client who is scheduled for surgery in the morning. Which of the following is the most important preoperative priority for the nurse?

4 :
A 56-year-old patient is scheduled for a laparoscopic cholecystectomy surgery in the morning. During preoperative period teaching, which of the following should the nurse include:

5 :
A nurse is assessing a patient on postoperative day 3 after abdominal surgery. Which of the following findings is most indicative off wound infection?

6 :
What are the key focus areas of the National Patient Safety Goals for surgery?

7 :
The nurse is planning care for a patient who is having surgery at 9 am today. Which of the following assessment data would you report to the Health Care Provider? Select all that apply.

8 :
A postoperative patient has a Jackson-Pratt (JP) drain in place. Which of the follow nursing interventions is most appropriate for ensuring proper function and preventing complications of the JP drain?

9 :
A nurse is caring for a patient in the immediate post-operative period following abdominal surgery. Which of the following assessments is the highest priority during the first hour post-op?

NUR 105 Eve A Exam-1

No.

1 : A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

2 : A nurse is caring for a postoperative patient who is using a patient-controlled analgesia (PCA) [ump with morphine]. Which of the following nursing interventions is the most appropriate to ensure safe and effective pain management?

3 : A nurse is caring for a client who is scheduled for surgery in the morning. Which of the following is the most important preoperative priority for the nurse?

4 : A 56-year-old patient is scheduled for a laparoscopic cholecystectomy surgery in the morning. During preoperative period teaching, which of the following should the nurse include:

5 : A nurse is assessing a patient on postoperative day 3 after abdominal surgery. Which of the following findings is most indicative off wound infection?

6 : What are the key focus areas of the National Patient Safety Goals for surgery?

7 : The nurse is planning care for a patient who is having surgery at 9 am today. Which of the following assessment data would you report to the Health Care Provider? Select all that apply.

8 : A postoperative patient has a Jackson-Pratt (JP) drain in place. Which of the follow nursing interventions is most appropriate for ensuring proper function and preventing complications of the JP drain?

9 : A nurse is caring for a patient in the immediate post-operative period following abdominal surgery. Which of the following assessments is the highest priority during the first hour post-op?

1 :
A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

2 :
A nurse is caring for a postoperative patient who is using a patient-controlled analgesia (PCA) [ump with morphine]. Which of the following nursing interventions is the most appropriate to ensure safe and effective pain management?

3 :
A nurse is caring for a client who is scheduled for surgery in the morning. Which of the following is the most important preoperative priority for the nurse?

4 :
A 56-year-old patient is scheduled for a laparoscopic cholecystectomy surgery in the morning. During preoperative period teaching, which of the following should the nurse include:

5 :
A nurse is assessing a patient on postoperative day 3 after abdominal surgery. Which of the following findings is most indicative off wound infection?

6 :
What are the key focus areas of the National Patient Safety Goals for surgery?

7 :
The nurse is planning care for a patient who is having surgery at 9 am today. Which of the following assessment data would you report to the Health Care Provider? Select all that apply.

8 :
A postoperative patient has a Jackson-Pratt (JP) drain in place. Which of the follow nursing interventions is most appropriate for ensuring proper function and preventing complications of the JP drain?

9 :
A nurse is caring for a patient in the immediate post-operative period following abdominal surgery. Which of the following assessments is the highest priority during the first hour post-op?