A nurse in an emergency department is preparing a client for emergency surgery. The
client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?
Obtain consent for surgery.
Insert an indwelling urinary catheter.
Apply antiembolic stockings.
Insert an NG tube.
The Correct Answer is A
The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.
The other actions are important but not as urgent as obtaining consent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
Correct Answer is ["100"]
Explanation
The correct answer is 100 mL/hr. To calculate this, use the formula: rate (mL/hr) = volume (mL) / time (hr).
Therefores: rate = 150 mL / 1.5 hr = 100 mL/hr.
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