A 68-year-old client is scheduled for elective hip replacement. The nurse reviews the pre-op checklist and finds that the patient has not voided. What is the best action?

• Proceed since it's not essential before surgery

• Instruct the patient to void to prevent intraoperative retention

• Notify the surgeon to delay the procedure

• Insert a Foley catheter without provider order

A patient in the PACU is drowsy with a respiratory rate of 9 breaths/min after IV morphine. What is the nurse’s priority action?

• Place in lateral position and monitor

• Administer naloxone and support airway

• Recheck vital signs in 15 minutes

• Elevate head of bed and stimulate gently

A scrub nurse touches the sterile field with an ungloved hand during setup. What should the circulating nurse do?

• Note the error and observe the procedure

• Stop the setup and replace contaminated items

• Document the event at the end of surgery

• Wipe the area with antiseptic

A patient becomes pale and hypotensive in PACU. The abdomen is distended and firm. What is the priority?

• Offer oral fluids to restore volume

• Apply warm blankets and reassess

• Suspect internal bleeding and notify surgeon

• Administer antiemetics

A nurse is reinforcing DVT prevention education. Which statements indicate a need for further teaching? Select all that apply.

• I’ll wait for the nurse before I move.

• I’ll sit still to avoid disrupting the surgical site.

• I’ll flex my ankles and wiggle my toes.

• Compression stockings help blood flow.

• I’ll avoid deep breathing since it hurts.

A patient with COPD is scheduled for surgery and continues smoking. Which finding is most concerning pre-op?

• Mild anxiety about surgery

• Decreased oxygenation and retained secretions

• Missed dose of bronchodilatorRequest for home oxygen post-op

All of the following are expected side effects of spinal anesthesia EXCEPT:

• Bradycardia

• Hypotension

• Tachycardia

• Sensory loss below the block

A post-op patient suddenly complains of chest pain and dyspnea. Vitals: HR 124, RR 30, SpO₂ 88%. What’s the priority?

• Apply oxygen and call respiratory therapy

• Suspect PE and activate rapid response

• Administer nitroglycerin

• Lower HOB and administer morphine

The patient just received spinal anesthesia and reports nausea and dizziness. BP is 80/42. What is the priority?

• Administer IV fluids rapidly and notify provider

• Raise the head of bed

• Reassure the patient

• Apply warm blankets

Which conditions would require delay or cancellation of elective surgery? Select all that apply.

• Temp of 38.6°C

• INR 5.0 on warfarin

• WBC 16,000 with chills

• Well-controlled diabetes

• Stable BP with mild anxiety