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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice Areason:

Placing pillows under the client's knees might be useful for comfort, but it doesn't directly address the risk of DVT.

Choice Breason:

Discouraging leg exercises while in bed is not recommended because it can lead to decreased circulation and an increased risk of blood clot formation.

Choice C reason:

Applying compression stockings to the lower extremities is recommendable. After an open cholecystectomy surgery, the client is at risk for developing deep vein thrombosis (DVT) due to reduced mobility and surgical trauma. Applying compression stockings to the lower extremities can help improve blood circulation and reduce the risk of blood clot formation.

Choice D reason:

Avoiding the use of anticoagulants is not recommendable, if prescribed by the healthcare provider, could be detrimental in preventing postoperative complications like DVT. Anticoagulants are often used to prevent clot formation in high-risk surgical patients.

A. The client reports being extremely thirsty with a sore throat. B. The client's abdomen becomes distended and firm. C. The drainage is bright green in color with brown fecal material D. The amount of drainage is gradually decreasing

Correct Answer is C

Explanation

Choice A Reason:

The client reports being extremely thirsty with a sore throat - This could be due to the presence of the NG tube and suctioning, but it is not as immediately concerning as the change in drainage colour.

Choice B Reason:

The client's abdomen becomes distended and firm - While this could indicate a possible complication, it is not as directly related to the change in drainage colour.

Choice C Reason:

The drainage is bright green in colour with brown faecal material the finding that the drainage from the NG tube is bright green in colour with brown faecal material should be reported to the provider. This change in the colour and appearance of the drainage can be indicative of bilious (greenish-yellow) vomiting, which may suggest an obstruction or another underlying issue. It's important to assess the client's condition and inform the provider about any significant changes in their symptoms.

Choice D Reason:

The amount of drainage is gradually decreasing - Gradually decreasing drainage could be expected as the condition improves, but it's not as alarming as a change in the drainage colour.

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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

A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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