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 NG tube.
Apply antiembolic stockings
insert an indwelling armory catheter
The Correct Answer is A
Choice A reason:
Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or
Choice B reason:
Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.
Choice C reason:
Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.
Choice D reason:
Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I can give you a list of other people who had the same procedure." - This response might not address the client's concerns and could potentially violate privacy and confidentiality.
Choice B Reason:
"I can give you additional information about the procedure." Response B is an appropriate and supportive response. The client is expressing uncertainty about the mastectomy, so offering more information about the procedure can help the client make an informed decision. Providing accurate and detailed information allows the client to better understand their options and the potential benefits and risks of the procedure.
Choice C Reason:
"You will be cancer-free if you have the procedure." - Making a guarantee of being cancer-free after the procedure might be misleading and overly optimistic. While a mastectomy can treat cancer in some cases, it's important to provide realistic information.
Choice D Reason:
"You should get a second opinion regarding the procedure." - While seeking a second opinion can be valuable, this response might not directly address the client's immediate concerns about the procedure. Providing information first and then discussing the option of a second opinion might be a more balanced approach.

Correct Answer is B
Explanation
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
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