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
Prealbumin is a protein that is produced by the liver and is used as a marker of nutritional status.
It has a short half-life, so changes in pre albumin levels can reflect recent changes in nutritional status.
Monitoring pre albumin levels can help assess the effectiveness of total parenteral nutrition.
Lipase is an enzyme that is produced by the pancreas and is not used to monitor overall nutritional status.
B) C-reactive protein is a marker of inflammation and is not used to monitor overall nutritional status.
D) Creatinine is a waste product that is produced by muscle metabolism and is not used to monitor overall nutritional status.
Correct Answer is C
Explanation
Furosemide is a loop diuretic that can cause loss of potassium from the body.
A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
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