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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Recommending staying at a local shelter might not be appropriate unless the client's health is in immediate danger due to the low temperature. It's better to explore other options first.
Choice B reason:
Contacting the client's family members about their financial status might not be necessary or respectful of the client's privacy without their consent.
Choice C reason:
Contact the local Department of Health and Human Services for the client. Contacting the local Department of Health and Human Services can help ensure that appropriate resources and assistance are provided to the client. They may have programs or services available to assist individuals who are struggling to afford heating during the winter. This action addresses the immediate concern of the client's health and the living environment.
Choice D reason:
Providing information about the dangers of hypothermia is important, but the client's current situation of living in a cold environment should be addressed first. The nurse can provide this information along with appropriate resources to help the client.
Correct Answer is D
Explanation
Choice A Reason:
Increased potassium level is incorrect. Valsartan does not typically cause an increase in potassium levels.
Choice B Reason:
Decreased urinary output is incorrect. Valsartan is not directly associated with changes in urinary output.
Choice C Reason:
Increased heart rate is incorrect. Valsartan generally does not lead to an increased heart rate; it is more likely to help regulate heart rate and reduce strain on the heart.
Choice D Reason:
Decreased blood pressure is correct. Valsartan is an angiotensin II receptor blocker (ARB) commonly used to treat conditions such as heart failure and hypertension. One of its primary effects is to dilate blood vessels and lower blood pressure. Therefore, a decreased blood pressure would indicate that the medication is effective in achieving its therapeutic goal of reducing the workload on the heart and improving circulation.
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