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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. Creatinine 0.8 mi/dl. B. Weight gain 1.1 kg (2.4 lb) in 24 hr C. Peripheral pulses 2+ bilaterally D. Urine specific gravity 1.045

Correct Answer is B

Explanation

Weight gain in a short period of time indicates fluid retention, which can worsen the client's condition and lead to complications such as pulmonary edema and hypertension. The nurse should report this finding to the provider and monitor the client's fluid balance and electrolytes.

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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?

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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?