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
Wear a lead apron when providing client care. Internal radiation therapy (brachytherapy) is a type of treatment that uses a radioactive source placed inside or near the tumor . The nurse should wear a lead apron to protect themselves from exposure to radiation when caring for the client. The other actions are not appropriate for a client receiving internal radiation therapy.
Correct Answer is B
Explanation
A WBC count of 20,000/mm3 indicates infection and inflammation, which is expected in osteomyelitis. Long-term IV antibiotic therapy is a common treatment for osteomyelitis and may require a referral to avoid peripherl thrombophlebitis. Furosemide is a diuretic that may be prescribed for clients who have fluid retention or hypertension, which are not related to osteomyelitis. A HbA1c of 6% indicates good glycemic control for a client with type 2 diabetes mellitus, which can help prevent complications and infections.
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