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 D

Explanation

Positive end-expiratory pressure (PEEP) is a mode of mechanical ventilation that maintains a positive pressure in the airways at the end of expiration, preventing alveolar collapse and improving oxygenation. PEEP does not affect tidal volume, inspiratory pressure, or ventilation rate, which are determined by other ventilator settings.

A. Apply an ice pack to the client's knee. B. Place pillows under the client's knee. C. Gently massage the area around the client's incision. D. Perform range-of-motion exercises to the client's knee.

Correct Answer is A

Explanation

Applying an ice pack to the client's knee can help reduce inflammation, swelling, and pain after a total knee arthroplasty. The nurse should avoid placing pillows under the client's knee, as this can cause flexion contractures and impair mobility and healing. Massaging or manipulating the incision site can increase pain and risk of infection or bleeding. Range-of-motion exercises are important for recovery, but they should be done with caution and under supervision, not when the client is experiencing severe pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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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?