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 B
Explanation
To assess a client for a positive Chvostek’s sign, the nurse should tap gently on the cheek, specifically two centimeters in front of the ear, over the facial nerve (also known as CN VII). This test is used to check for hypocalcemia, a condition that can lead to tetany, which is the involuntary contraction of muscles. A twitch of the facial muscles in response to this tapping indicates a positive Chvostek’s sign. This is particularly relevant following a thyroidectomy, as the procedure can indirectly affect the parathyroid glands, potentially leading to hypocalcemia
Correct Answer is C
Explanation
In C, There is ST segment elevation in this ECG which is indicative of a myocardial infarction
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