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?
Insert an indwelling urinary catheter.
Insert an NG tube.
Obtain consent for surgery.
Apply antiembolic stockings.
The Correct Answer is B
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Wearing a lead apron can help protect the nurse from radiation exposure while providing care to a client receiving internal radiation therapy.
Choice A is incorrect because visitors may need to limit their contact with the client and follow specific safety precautions.
Choice B is incorrect because a dosimeter film badge is worn by the nurse to measure radiation exposure, not placed on the client’s door.
Choice D is incorrect because the door to the client’s room may need to be kept closed as a safety precaution 2.
Correct Answer is A
Explanation
The nurse’s priority assessment in the PACU (Post-Anesthesia Care Unit) should be the client’s respiratory status.
This is because the client is recovering from anesthesia and may have an altered respiratory function.
Choice B, assessing the surgical site, is not an answer because it is not the priority assessment for a client in the PACU.
Choice C, assessing the level of consciousness, is not an answer because it is not the priority assessment for a client in the PACU.
Choice D, assessing the pain level, is not an answer because it is not the priority assessment for a client in the PACU.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today