Question

A nurse from the recovery area is caring for a client who is beginning to wake up from anesthesia following a foot amputation. Which of the following priority postoperative complications should the nurse expect the patient to experience first?

Answer 1

Correct Answers:

Pain

Rationale :

Pain

💠 Pain is the earliest postoperative complication once anesthesia begins to wear off and consciousness returns.

💠 Surgical amputation causes significant tissue and nerve injury, which immediately activates nociceptors.

💠 Inflammatory mediators are released at the incision site, intensifying acute postoperative pain.

💠 Sympathetic stimulation from pain increases heart rate and blood pressure, making early management essential.

💠 Pain assessment follows airway stabilization in PACU, making it the first expected complication on awakening.

Frequent falls

💠 The client is not ambulating in the immediate recovery phase, so falls are not the first complication expected.

💠 Fall risk increases later during mobility, not during initial emergence from anesthesia.

Delirium

💠 Postoperative delirium develops after full emergence, not as the first complication during awakening.

💠 Pain is more immediate and physiologically predictable than cognitive disturbances.

Hypothermia

💠 Hypothermia may occur intraoperatively, but it is often managed before awakening.

💠 Pain perception occurs immediately once awareness returns, making it the first expected issue.

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Answer 2

Correct Answers:

Providing open communication and updates on the client's condition

Rationale :

💠 Open communication reduces anxiety and uncertainty for family members during a critical emergency situation.

💠 Regular updates promote trust and transparency, strengthening the therapeutic relationship between the healthcare team and the family.

💠 Families experiencing crisis benefit from inclusion, as it helps them feel supported and involved in the client’s care.

💠 Clear explanations enhance understanding of the client’s condition and interventions, allowing informed participation in decisions when needed.

💠 Therapeutic communication demonstrates empathy and compassion, which is essential during life-threatening events.

Asking the charge nurse to manage all communication with the client’s family

💠 Delegating all communication removes the primary nurse’s therapeutic role, limiting direct support to the family.

💠 Families benefit from consistent communication, especially from the nurse directly involved in the client’s care.

Asking the family to wait in the waiting room during the entirety of the care

💠 Excluding the family increases stress and feelings of helplessness during a crisis.

💠 Family presence, when appropriate, can provide emotional support, rather than complete separation.

Notifying the family once the client's care has been completed

💠 Delaying communication prolongs anxiety and uncertainty for the family.

💠 Therapeutic care requires ongoing updates, not just final outcomes.

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Answer 3

Correct Answers

Blank 1 Correct Option: postoperative pneumonia
Blank 2 Correct Option: vital signs

Rationale :

🔷 The client demonstrates hypoxemia with an oxygen saturation of 88%, which indicates impaired gas exchange following surgery under general anesthesia.

🔷 Tachypnea (RR 24/min) and labored respirations suggest respiratory compromise, increasing the risk of atelectasis and subsequent pneumonia.

🔷 General anesthesia and abdominal surgery decrease lung expansion, promoting secretion retention and reduced cough effort.

🔷 Fever of 38.8°C (101.8°F) supports a possible early infectious process, especially in the context of bowel rupture and abdominal surgery.

🔷 Immobility and postoperative pain limit deep breathing, further predisposing the client to pulmonary complications.

Hypervolemia

🔷 There is no evidence of fluid overload such as crackles or edema.

🔷 Blood pressure and clinical findings do not indicate excess circulating volume.

Pressure Ulcers

🔷 Skin is warm, dry, and intact on assessment.

🔷 There is no documentation of prolonged immobility or skin breakdown.

Malignant Hyperthermia

🔷 Malignant hyperthermia presents with muscle rigidity and rapidly rising CO₂, which are not documented.

🔷 Temperature elevation alone without rigidity or severe acidosis does not confirm this condition.

Pulmonary Embolism

🔷 Although tachycardia and hypoxemia are present, there is no sudden chest pain or acute circulatory collapse noted.

🔷 Findings are more consistent with hypoventilation and postoperative pulmonary complications.

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Answer 4

Correct Answers:

Place side rails in an upright position.

Rationale :

🔶 Preoperative medications often include sedatives and opioids, which can cause drowsiness, dizziness, and impaired coordination.

🔶 Raising the side rails promotes client safety by reducing the risk of falls once the medication begins to take effect.

🔶 Sedation decreases protective reflexes and alertness, increasing injury risk if safety measures are not implemented.

🔶 Safety is the priority after medication administration, especially when the client’s level of consciousness may decline.

🔶 Implementing fall precautions aligns with postoperative and perioperative nursing standards for clients receiving sedatives.

Educate the client about the surgical procedure

🔶 Teaching should be completed before preoperative sedation, when the client can fully comprehend information.

🔶 Sedation impairs cognitive function, limiting the client’s ability to retain new information.

Have the client sign the informed consent

🔶 Informed consent must be signed before administering sedative preoperative medications.

🔶 A sedated client cannot legally provide informed consent, as decision-making capacity may be impaired.

Provide assistance to the bathroom

🔶 Ambulation after sedation increases fall risk, even with assistance.

🔶 The client should remain in bed once preoperative medications are given.

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Answer 5

Correct Answers:

Professional practice evaluation

Rationale :

🔵 Self-reflection and requesting feedback are core components of professional growth in nursing practice.

🔵 Seeking supervisor input demonstrates commitment to quality improvement and accountability in clinical performance.

🔵 Evaluating one’s contribution to the care plan supports competency and safe transplant care delivery.

🔵 Ongoing appraisal of performance aligns with established professional standards in transplant nursing.

🔵 This behavior reflects accountability and dedication to continuous professional development.

Environmental health

🔵 Environmental health focuses on maintaining a safe care setting.

🔵 It does not address self-assessment of professional performance.

Education

🔵 Education involves teaching patients or colleagues.

🔵 The scenario describes evaluation of performance, not instruction.

Evidence-based practice

🔵 Evidence-based practice integrates research into clinical decisions.

🔵 The nurse is demonstrating performance evaluation, not research application.

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Answer 6

Correct Answers:

"Lie on your back or sit in a supportive chair."

Rationale :

🟢 Proper positioning is essential to allow full expansion of the diaphragm during deep breathing exercises.

🟢 Lying supine or sitting upright promotes maximum lung expansion and improves ventilation.

🟢 A supported position reduces accessory muscle use and encourages effective diaphragmatic movement.

🟢 Diaphragmatic breathing helps prevent atelectasis and postoperative pulmonary complications.

🟢 Teaching correct body alignment enhances the effectiveness of postoperative respiratory exercises.

"Repeat these steps ten times quickly."

🟢 Diaphragmatic breathing should be performed slowly and rhythmically, not quickly.

🟢 Rapid breathing may lead to hyperventilation and decreased effectiveness.

"After placing your hands on your abdomen, blow out quickly two times."

🟢 Exhalation should be slow and controlled, not forceful or rapid.

🟢 Quick blowing does not promote effective diaphragm engagement.

"Lie on your side."

🟢 Side-lying does not allow optimal diaphragm expansion.

🟢 Upright or supine positioning is preferred for effective lung inflation.

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Answer 7

Correct Answers:

Background

Rationale :

🟣 Background includes relevant historical information that led to the current admission or condition.

🟣 Reporting that the client had head trauma from a fall at 0800 provides context about how the injury occurred.

🟣 The mechanism of injury, such as hitting the edge of the bathtub, is part of the clinical history.

🟣 Background data supports understanding of potential complications like intracranial bleeding.

🟣 In SBAR, background explains events preceding the present status, not the current assessment findings.

Assessment

🟣 Assessment refers to the nurse’s clinical findings or interpretation of the client’s condition.

🟣 The statement describes the event, not current clinical evaluation data.

Recommendation

🟣 Recommendation includes suggested actions or next steps in care.

🟣 No proposed intervention or request is included in the statement.

Situation

🟣 Situation identifies the immediate problem or reason for communication.

🟣 The report describes past history rather than the current presenting concern.

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Answer 8

Correct Answers:

What day and time did the assault take place?

Rationale :

🔴 Determining the exact time of exposure is critical because HIV post-exposure prophylaxis (PEP) must be started within 72 hours to be effective.

🔴 Early initiation of antiretroviral therapy significantly reduces the risk of viral replication and infection.

🔴 The timing directly guides urgent clinical decision-making, including laboratory testing and medication administration.

🔴 This question prioritizes client safety and infection prevention, which is the immediate physiological concern.

🔴 Establishing the timeframe ensures evidence-based implementation of HIV prophylaxis protocols.

Do you give us permission to call the police?

🔴 Obtaining consent for police notification is important for legal and ethical reasons.

🔴 However, it does not address the immediate medical urgency related to HIV exposure.

Who was the individual who assaulted you?

🔴 Identifying the assailant may assist in legal investigation.

🔴 It does not determine eligibility for time-sensitive prophylactic treatment.

Where did the assault occur?

🔴 Location details are relevant for forensic documentation.

🔴 This information does not impact urgent infection prevention interventions.

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Answer 9

Correct Answers:

Background

Rationale :

🟡 Family history of malignant hyperthermia is part of the client’s relevant past medical information.

🟡 Background in SBAR includes pertinent history that may affect surgical and anesthesia management.

🟡 Malignant hyperthermia is a genetic condition triggered by certain anesthetic agents.

🟡 Including this information alerts the team to use non-triggering anesthetics and prepare emergency medications like dantrolene.

🟡 This detail supports safe perioperative planning by providing essential risk-related history.

Situation

🟡 Situation describes the immediate reason for communication.

🟡 A family history is not the current presenting clinical problem.

Assessment

🟡 Assessment involves current clinical findings or nurse evaluation.

🟡 Family history is historical data, not a present clinical status finding.

Recommendation

🟡 Recommendation includes proposed actions or requests.

🟡 The question asks where to place historical information, not suggested interventions.

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Answer 10

Correct Answers:

Follow their agency policy regarding media relations.

Rationale :

🔵 Agency policy guides how and by whom information is released during disasters or emergencies.

🔵 Nurses must protect client confidentiality in accordance with HIPAA regulations and institutional standards.

🔵 Media communication is typically handled by designated public information officers or administration.

🔵 Following policy ensures accurate, consistent, and legally appropriate public communication.

🔵 This action demonstrates professional accountability and adherence to ethical nursing standards.

Answer the questions to the best of the nurse's knowledge

🔵 Sharing information independently risks violating confidentiality laws.

🔵 Individual nurses are not authorized sources for official media updates.

Send the request for information to a co-worker who has more time to answer

🔵 Redirecting to another staff member does not ensure compliance with media policy.

🔵 Only designated representatives should provide public statements.

Ignore the request for information

🔵 Simply ignoring the request does not reflect professional communication standards.

🔵 Proper procedure requires following established organizational protocol.

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QLexNursing

1 :
A nurse from the recovery area is caring for a client who is beginning to wake up from anesthesia following a foot amputation. Which of the following priority postoperative complications should the nurse expect the patient to experience first?

2 :
A client in the emergency department is in critical condition. The client's nurse recognizes that which of the following actions would be therapeutic for the family?

3 :
A circulating nurse is caring for a client undergoing emergency surgery.

Correct Answers

4 :
A nurse has administered preoperative medications to a client. Which of the following actions should the nurse implement?

6 :
A nurse is reinforcing teaching about diaphragmatic breathing with a client as part of preparing them for postoperative care. Which of the following instructions should the nurse include?

8 :
A nurse is caring for a client who was sexually assaulted. Data collection indicates that the client might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?

9 :
A nurse is reviewing the client's medical record and notices a family history of malignant hyperthermia. In which of the following sections of the SBAR communication tool should the nurse include this information when completing handoff to the surgical team?

10 :
A nurse is caring for clients in the emergency department during a regional disaster. A reporter from the local TV station reaches out to the nurse via social media and asks for an update. Which of the following is the nurse's best course of action?

QLexNursing

1 : A nurse from the recovery area is caring for a client who is beginning to wake up from anesthesia following a foot amputation. Which of the following priority postoperative complications should the nurse expect the patient to experience first?

2 : A client in the emergency department is in critical condition. The client's nurse recognizes that which of the following actions would be therapeutic for the family?

3 : A circulating nurse is caring for a client undergoing emergency surgery.

Correct Answers

4 : A nurse has administered preoperative medications to a client. Which of the following actions should the nurse implement?

6 : A nurse is reinforcing teaching about diaphragmatic breathing with a client as part of preparing them for postoperative care. Which of the following instructions should the nurse include?

8 : A nurse is caring for a client who was sexually assaulted. Data collection indicates that the client might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?

9 : A nurse is reviewing the client's medical record and notices a family history of malignant hyperthermia. In which of the following sections of the SBAR communication tool should the nurse include this information when completing handoff to the surgical team?

10 : A nurse is caring for clients in the emergency department during a regional disaster. A reporter from the local TV station reaches out to the nurse via social media and asks for an update. Which of the following is the nurse's best course of action?

1 :
A nurse from the recovery area is caring for a client who is beginning to wake up from anesthesia following a foot amputation. Which of the following priority postoperative complications should the nurse expect the patient to experience first?

2 :
A client in the emergency department is in critical condition. The client's nurse recognizes that which of the following actions would be therapeutic for the family?

3 :
A circulating nurse is caring for a client undergoing emergency surgery.

4 :
A nurse has administered preoperative medications to a client. Which of the following actions should the nurse implement?

6 :
A nurse is reinforcing teaching about diaphragmatic breathing with a client as part of preparing them for postoperative care. Which of the following instructions should the nurse include?

8 :
A nurse is caring for a client who was sexually assaulted. Data collection indicates that the client might have been exposed to human immunodeficiency virus (HIV). Which of the following questions is most important to ask the client?

9 :
A nurse is reviewing the client's medical record and notices a family history of malignant hyperthermia. In which of the following sections of the SBAR communication tool should the nurse include this information when completing handoff to the surgical team?

10 :
A nurse is caring for clients in the emergency department during a regional disaster. A reporter from the local TV station reaches out to the nurse via social media and asks for an update. Which of the following is the nurse's best course of action?