Perioperative

Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1.Potential for hemorrhaging. 2.Potential for injury. 3.Potential for fluid volume excess. 4.Potential for infection.

1 All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.-

The nurse is planning the care of the surgical client having conscious sedation. Which intervention has highest priority? 1.Assess the client's respiratory status. 2.Monitor the client's urinary output. 3.Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused.

1 Assessing the respiratory rate, rhythm,and depth is the most important action.

The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? 1.Take routine vital signs on clients. 2.Check the Jackson Pratt insertion site. 3.Hang the client's next IV bag. 4.Ensure the client obtains pain relief.

1 Taking the vital signs of the stable client may be delegated to the UAP.

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? (Select all that apply) 1. The client has loose, decayed teeth. 2. The client is experiencing anxiety. 3. The client smokes two (2) packs of cigarettes a day. 4. The client has had a chest x-ray which does not show infiltrates. 5. The client reports using herbs.

1. The client has loose, decayed teeth. 3. The client smokes two (2) packs of cigarettes a day. 5. the client reports using herbs. Rationale: 1. loose teeth or caries need to be reported to the anesthesiologist so he or she can make provisions to prevent breaking the teeth and causing the client to possible aspirate pieces. 3. Smokers are at higher risk for complications from anesthesia. 5. Herbs - for example, St. John's wort, licorice, and ginkgo - have serious interactions with anesthis and with bodily functions such as coagulation.

The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? 1.The client having open-heart surgery 2.The client having a biopsy of the breast. 3.The client having laser eye surgery. 4.The client having a laparoscopic knee repair.

2 The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple.

The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? 1.The 16-year-old client in the dorsal recumbent position having an appendectomy. 2.The 68-year-old client in the Trendelenburg position having a cholecystectomy. 3.The 45-year-old client in the reverse Trendelenburg position having a biopsy. 4.The 22-year-old client in the lateral position having a nephrectomy.

2 The client's age, along with positioning with increased weight and pressure on the shoulders, puts this client at higher risk.

Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1.Pad the client's elbows and knees. 2.Apply soft restraint straps to the extremities. 3.Prepare the client's incision site. 4.Document the temperature of the room.

2 This action would prevent the client from falling off the table, which is the highest priority.

Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain? 1. Ineffective coping. 2. Potential for injury. 3. Alteration in comfort. 4. Altered sensory input.

3 1. This is a psychosocial problem, which is not appropriate for an acute physiological problem. 2. A potential problem is not priority for a client in acute pain. 3. Alteration in comfort is addressing the client's acute pain. 4. Altered sensory input does not address the client's acute physical pain. TEST-TAKING HINT: The test taker should be familiar with NANDA's list of client problems and nursing diagnoses, which includes alteration in comfort for pain. Potential problems do not have priority over actual problems.

The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1.Place the sponge back where it was. 2.Tell the technician not to waste supplies. 3.Do nothing because this is the correct procedure. 4.Take the sponge out of the room immediately.

3 The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed,not used, and placed in a designated area to be counted later.

Which situation demonstrates the circulating nurse acting as the client's advocate? 1.Plays the client's favorite audio book during surgery. 2.Keeps the family informed of the findings of the surgery. 3.Keeps the operating room door closed at all times. 4.Calls the client by the first name when the client is recovering.

3 This would keep the client's dignity by maintaining privacy. With this action,the nurse is speaking for the client while the client cannot speak as a result of anesthesia; this is an example of client advocacy.

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? 1.Notify the client's surgeon. 2.Complete an occurrence report. 3.Contact the surgical manager. 4.Re-count all sponges.

4 A re-count of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field,such as the floor or a lower shelf.

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL 2. Bleeding time 2 minutes 3. Hemoglobin 15 g/dL 4. Potassium 2.4 mEq/L

4. Potassium 2.4 mEq/L Rationale: This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.

Which nursing intervention is priority for the client experiencing acute pain? 1. Assess the client's verbal and nonverbal behavior. 2. Wait for the client to request pain medication. 3. Administer the pain medication on a scheduled basis. 4. Teach the client to use only imagery every hour for the pain.

1 1. Assessing verbal and nonverbal cues is the priority intervention because pain is subjective. 2. Some clients are hesitant to ask for medication or believe it is a sign of weakness to ask. 3. There are times when pain medications are given on a routine basis, but it is not the best answer because assessment takes priority. 4. Alternative therapies, such as imagery, are used in combination with medications, but they never replace medications. TEST-TAKING HINT: Options such as option "4" which have absolute words such as "only" usually can be eliminated as a correct answer. The test taker should remember to apply the nursing process, and the first step is assessment.

The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1.Assess the client's breath sounds. 2.Apply oxygen via nasal cannula. 3.Take the client's blood pressure. 4.Monitor the pulse oximeter reading.

1 The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway,breathing, and circulation.

Which activities are the circulating nurse's responsibilities in the operating room? 1.Monitor the position of the client, prepare the surgical site, and ensure the client's safety. 2.Give preoperative medication in the holding area and monitor the client's response to anesthesia. 3.Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. 4.Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

1 The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR;keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment.

The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? 1.The client has no injuries from the OR equipment. 2.The client has no postoperative infection. 3.The client has stable vital signs during surgery. 4.The client recovers from anesthesia.

1 This expected outcome addresses the safety of the client while in the OR.

The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1.Prepare ice packs and mix dantrolene sodium. 2.Request the defibrillator be brought into the OR. 3.Draw a PTT and prepare a heparin drip. 4.Obtain finger stick blood glucose immediately.

1 Unexplained tachycardia, hypotension,and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and dantrolene sodium.

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? 1. "I will be glad when this is over so I can go home today." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I can practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."

1. "I will be glad when this is over so I can go home today." Rationale: the client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1. Notify the surgeon about the client's request to wear the medal. 2. Tape the medal to the client and allow the client to wear the medal. 3. Request the family member take the medal prior to surgery. 4. Explain taking the medal to surgery is against the policy.

2. Tape the medal to the client and allow the client to wear the medal. Rationale: the medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to the client's care.

The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? Select all that apply. 1. Compare the hospital number on the MAR to the client's bracelet. 2. Have a witness verify the wasted portion of the narcotic. 3. Assess the client's vital signs prior to administration. 4. Determine if the client has any allergies to medications. 5. Clarify all pain medication orders with the health-care provider.

1, 3, 4 1. This procedure ensures client safety by preventing medication from being given to the wrong client. 2. This is a legal requirement, not a safety issue. 3. This intervention would prevent giving a narcotic to a client who is unstable or compromised. 4. Determining allergies addresses client safety. 5. It would not be realistic to recheck all orders. TEST-TAKING HINT: This question specifically asks the test taker to identify interventions for safely administering medication to the client. Therefore, options "2" and "5" could be eliminated because they do not address the client's safety. This is an alternate-type question requiring the test taker to select more than one (1) option as the correct answer.

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? 1. Notify the surgeon of the client's status 2. Continue giving enemas until clear 3. Increase the client's IV fluid rate 4. Obtain STAT serum electrolytes

1. Notify the surgeon of the client's status Rationale: 1. The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances. 2. Administering more enemas will put the client at further risk for fluid volume deficit and electrolyte imbalances. 3. The IV may need to be increased, but the nurse would need an order for this intervention. 4. the electrolyte status may need to be assessed, but the nurse would need an order for this intervention.

Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain? 1. Use words a four (4)-year-old child can remember. 2. Explain the 0-to-10 pain scale to the child's parent. 3. Have the child point to the face which describes the pain. 4. Administer the medication every four (4) hours.

3 1. The nurse should use words a four (4)-year-old child understands and remembers, but this is not the best way to assess pain. 2. A four (4)-year child cannot be expected to use the numeric pain scale because of lack of cognitive abilities, and explaining it to the parents does not address the child's pain. 3. The Faces Scale is the best way to assess pain in a four (4)-year-old child. 4. This does not assess the child's pain, and administering the pain medication every four (4) hours may compromise the child's safety. TEST-TAKING HINT: When age is listed, it is an indication the question is asking for age-specific information. The test taker should consider developmental levels for that particular age.

The nurse identifies the nursing diagnosis "risk for injury related to positioning"for the client in the operating room. Which nursing intervention should the nurse implement? 1.Avoid using the cautery unit which does not have a biomedical tag on it. 2.Carefully pad the client's elbows before covering the client with a blanket. 3.Apply a warming pad on the OR table before placing the client on the table. 4.Check the chart for any prescription or over-the-counter medication use.

2 Padding the elbows decreases pressure so nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis.

Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1.The client will be able to sit in the chair for 30 minutes. 2.The client will have a pulse oximetry reading of 97% on room air. 3.The client will have a urine output of 30 mL per hour. 4.The client will be able to distinguish sharp from dull sensations.

2 The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status;the alveoli can collapse, causing atelectasis.

The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement? 1. Determine why the client is not using the PCA pump. 2. Document the amount and take no action. 3. Chart the client is not having pain. 4. Contact the HCP and request oral medication.

1 1. Assessing why the client is not using the medication is a priority and then, based on the client's response, a plan of care can be determined. 2. The fact a client is not using pain medication warrants the nurse determining the cause so appropriate action can be taken. 3. This may or may not be why the client is not using the PCA pump. The nurse must first determine why the client is not using pain medication. 4. This may or may not be indicated, but until the nurse determines why the client is not taking the medication, this action should not be implemented.

The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement? 1. Administer pain medication as soon as the time frame allows. 2. Use nonpharmacological methods to replace medications. 3. Use cryotherapy after heat therapy because it works faster. 4. Instruct family members to administer medication with the PCA.

1 1. Pain medications should be administered at the frequency ordered by the HCP, not just when the client requests them, especially for acute pain. 2. Nonpharmacological methods should never replace medications, but they should be used in combination to help keep the client comfortable. 3. Cryotherapy (cold) is used immediately postoperative or postinjury. Heat applications are applied at a later time. 4. Only clients should activate the PCA to prevent overdosing. TEST-TAKING HINT: Option "4" should be eliminated because a basic concept is the client should be the person in control of the pain, not a family member; pain is subjective.

The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management? 1. "Have you ever had difficulty getting your pain controlled?" 2. "What types of surgery have you had in the last 10 years?" 3. "Have you ever been addicted to narcotics?" 4. "Do you have a list of your prescription medications?"

1 1. The answer to this request would indicate if the client has had a negative experience which may influence the client's pain management. 2. Previous surgeries would be pertinent information but not for pain management. 3. Before asking this question, the nurse should have specific information to suspect drug use. 4. Discussing the client's prescription medications is necessary, but asking for a list of medications will not address the client's pain management. TEST-TAKING HINT: Assessment, the first step of the nursing process, of pain perception is indicated when caring for a client with acute pain.

The client is complaining of left shoulder pain. Which intervention should the nurse implement first? 1. Assess the neurovascular status of the left hand. 2. Check the medication administration record (MAR). 3. Ask if the client wants pain medication. 4. Administer the client's pain medication.

1 1. The nurse should first assess the client for potential complications to determine if this expected pain or pain requiring notifying the health-care provider. 2. The nurse must check the MAR to determine when the last pain medication was administered, but it is not the first intervention. 3. The nurse must rule out complications which require medical intervention prior to medicating the client. 4. The nurse should not administer any pain medication prior to ruling out complications and checking the MAR. TEST-TAKING HINT: The test taker should apply the nursing process when answering the question and select an option that addresses assessment.

Which situation is an example of the nurse fulfilling the role of client advocate? 1. The nurse brings the client pain medication when it is due. 2. The nurse collaborates with other disciplines during the care conference. 3. The nurse contacts the health-care provider when pain relief is not obtained. 4. The nurse teaches the client to ask for medication before the pain gets to a "5." 40. Which statement should the nurse identify as the expected outcome for a client experiencing acute pain? 1. The client will have decreased use of medication. 2. The client will participate in self-care activities. 3. The client will use relaxation techniques. 4. The client will repeat instructions about medications.

2 1. A decrease in use of pain medication does not mean the client's pain is managed; the client may be concerned about possible addiction to the pain medication. 2. Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client's pain is tolerable. 3. Using relaxation techniques does not indicate the client's pain is under control. 4. This would be an expected outcome of a knowledge-deficit problem. TEST-TAKING HINT: The test taker must first determine what is the expected outcome, which should be "relief of pain," and then determine which option addresses the client's relief of pain.

Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain? 1. Take the pain medication to the room. 2. Apply an ice pack to the site of pain. 3. Check on the client 30 minutes after she takes the pain medication. 4. Observe the client's ability to use the PCA.

2 1. Medication administration cannot be delegated to a UAP. 2. This task does not require teaching, evaluating, or nursing judgment and therefore can be delegated. 3. Assessment cannot be delegated to a UAP. 4. Evaluation of teaching cannot be delegated to a UAP. TEST-TAKING HINT: The terms "observe" and "check" in options "3" and "4" are different from the term "evaluate," but reading the options, the tasks are clearly addressing the evaluation step of the nursing process. Evaluation cannot be delegated to the UAP.

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1.Alteration in comfort. 2.Risk for depressed respiratory pattern. 3.Potential for infection. 4.Fluid and electrolyte imbalance.

2 A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all apply. 1.Give a back rub to the client to relieve stiffness. 2.Apply ice packs to the axillary and groin areas. 3.Prepare an ice slush for the client to drink. 4.Prepare to administer dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket.

2, 4 Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. Dantrolene is the drug of choice for treatment.

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? (Select all that apply) 1. Perform passive range-of-motion exercises. 2. Discuss how to cough and deep breathe effectively 3. Tell the client he can have a meal in the PACU. 4. Teach ways to manage postoperative pain. 5. Discuss events which occur in the post-anesthesia care unit.

2. Discuss how to cough and deep breathe effectively 4. Teach ways to manage postoperative pain 5. Discuss events which occur in the post-anesthesia care unit. Rationale: 1. Passive means the nurse performs the range-of-motion exercises. The client in the PACU should do active range-of-motion exercises. 2. Coughing effectively aids in the removal of pooled secretions which can cause pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. 3. The client having abdominal surgery will be NPO until bowel sounds return, which will not occur in the PACU. 4. The client's postoperative pain should be kept within a tolerable range. 5. These interventions help decrease the client's anxiety.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1.Apply anti-embolism hose to the client. 2.Attach the drain to 20 cm suction. 3.Assess the client's vital signs. 4.Listen to the report from the anesthesiologist.

3 Assessing the client's status after transfer from the PACU should be the nurse's first intervention.

The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1.Call the surgeon and report the vital signs. 2.Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3.Elevate the feet and lower the head. 4.Monitor the vital signs every 15 minutes.

3 By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging

The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8˚F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1.Administer the antibiotic earlier than scheduled. 2.Change the dressing over the wound. 3.Have the client turn, cough, and deep breathe every two (2) hours. 4.Encourage the client to ambulate in the hall.

3 Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because, if a client has a fever within the first day,it is usually caused by a respiratory problem.

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1.Loss of sensation at the lumbar (L5) dermatome. 2.Absence of the client's posterior tibial pulse. 3.The client has a respiratory rate of eight (8). 4.The blood pressure is within 20% of client's baseline

3 If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? 1. "Don't worry about your surgery. It is safe." 2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of having this surgery." 4. "I understand how you feel. Surgery is frightening."

3. "Tell me about your fears of having this surgery." Rationale: 1. giving false reassurance. 2. "Why" is never therapeutic. 3. This statement focuses on the emotion which the client identified and is therapeutic. 4. This statement belittles the client's fear, and no person understands how another person feels.

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist. 2. Label the client's allergies on the front of the chart. 3. Ask the client what happens when he takes the codeine. 4. Document the allergy on the medication administration record.

3. Ask the client what happens when he takes the codeine. Rationale: The nurse should first assess the events which occurred when the client took this medication because many clients think a side effect, such as nausea, is an allergic reaction.

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? 1. The 65-year-old client who cannot read or write. 2. The 30-year-old client who does not understand English. 3. The 16-year-old client who has a fractured ankle. 4. The 80-year-old client who is not oriented to the day.

3. The 16-year-old client who has a fractured ankle. Rationale: A 16-year-old client is not legally able to give permission for surgery unless the adolescent has been given an emancipated status by a judge.

Which violation of surgical asepsis would require immediate intervention by the circulating nurse? 1.Surgical supplies were cleaned and sterilized prior to the case. 2.The circulating nurse is wearing a long-sleeved sterile gown. 3.Masks covering the mouth and nose are being worn by the surgical team. 4.The scrub nurse setting up the sterile field is wearing artificial nails.

4 According to the Centers for Disease Control and Prevention (CDC),the Association of Operating Room Nurses (AORN), and the Association for Practitioners in Infection Control,artificial nails harbor microorganisms, which increase the risk for infection.

The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1.The 4-year-old client who had a tonsillectomy and is able to swallow fluids. 2.The 74-year-old client with a repair of the left hip who is unable to ambulate. 3.The 24-year-old client who had an uncomplicated appendectomy the previous day. 4.The 80-year-old client with small bowel obstruction and congestive heart failure.

4 An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse.

Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1.Urine output was 160 mL in the past eight (8) hours. 2.Paralysis and parasthesia of the right leg. 3.T 99.0˚F, P 98, R 20, and BP 100/60. 4.Lungs are clear bilaterally in all lobes.

4 Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.

Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain? 1. Monitor the client's vital signs. 2. Verify the time of the last dose. 3. Check for the client's allergies. 4. Discuss the pain with the client.

4. 1. It is important to monitor vital signs, but it is not the priority intervention prior to administering the medication. 2. The nurse should verify the time the last dose was administered to determine the time the next dose could be administered, but this is not the priority intervention. 3. Prior to giving any medication, the nurse should assess any allergies, but it is not the priority intervention. 4. The nurse should question the client to rule out complications and to determine which medication and amount would be most appropriate for the client. This is assessment.

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Teach the client about coughing and deep breathing. 4. Assist the client to remove clothing and jewelry.

4. Assist the client to remove clothing and jewelry. Rationale: The nurse cannot delegate assessing or teaching to a UAP. The UAP can remove clothing and jewelry. The preoperative checklist requires analysis, which cannot be delegated.

The nurse is preparing a client for surgery. Which intervention should the nurse implement first? 1. Check the permit for the spouse's signature. 2. Take and document intake and output. 3. Administer the "on call" sedative. 4. Complete the preoperative checklist.

4. Complete the preoperative checklist. Rationale: Completing the preoperative checklist has the highest priority to ensure all details are completed without omissions.

The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? 1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. 2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion. 3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed. Rationale: The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side.