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 D

Explanation

Choice A Reason:

Blurred vision is incorrectly. Blurred vision is not a common complication of immobility and is more likely related to other factors.

Choice B Reason:

Polyuria is incorrect. Increased urination (polyuria) is not directly related to immobility; it can be caused by various factors, such as fluid intake, medications, or underlying medical conditions.

Choice C Reason:

Diarrhea is incorrect. While immobility can contribute to constipation due to reduced activity and decreased bowel motility, it is not typically associated with diarrhea

Choice D Reason:

Confusion is correct. Confusion can be a potential complication of immobility in bedridden clients. Prolonged immobility can lead to reduced sensory stimulation, altered sleep patterns, and decreased cognitive engagement, which can contribute to confusion and cognitive decline.

A. 75 mL of greenish-yellow drainage B. 150 mL of serosanguineous drainage C. 100 mL of red drainage D. 200 mL of brown drainage

Correct Answer is C

Explanation

Choice A reason:

75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.

Choice B reason:

150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.

Choice C reason:

100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.

Choice D reason:

200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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