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 D
Explanation
A pacemaker sends electrical signals to the heart to regulate the heartbeat.
On an electrocardiogram (ECG), these signals appear as small spikes followed by a QRS complex, which represents the contraction of the ventricles.
Choice A, A regular sinus rhythm, is not the correct answer because a regular sinus rhythm is a normal heart rhythm that originates from the sinoatrial (SA) node and does not involve a pacemaker.
Choice B, A chaotic, irregular rhythm, is not the correct answer because a pacemaker is designed to regulate the heartbeat and prevent chaotic or irregular rhythms.
Choice C, the Absence of any electrical activity, is not the correct answer because a pacemaker sends electrical signals to the heart to regulate its activity.
Correct Answer is C
Explanation
This statement indicates an understanding of the teaching because shaking the inhaler helps to mix the medicine inside the canister.
Choice A is incorrect because it is not necessary to clean the cap of the inhaler once per week.
Instead, it is important to clean the inhaler at least once a week or as directed.
Choice B is incorrect because one should inhale the medication slowly, not quickly.
Choice D is incorrect because one should wait 1 minute between puffs, not 15 seconds.
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