A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Advance from clear liquids as tolerated.

Cefazolin 1 gram IV every 6 hours.

Straight catheterization if unable to void.

Complete blood cell count (CBC) in the morning.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.

Choice B rationale

Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.

Choice C rationale

Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.

Choice D rationale

Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Assessing serum potassium levels every 4 hours is essential for clients receiving insulin to treat hyperkalemia. Insulin promotes the uptake of potassium into cells, potentially leading to hypokalemia. Frequent monitoring ensures prompt detection of abnormal potassium levels, enabling timely intervention.

Choice B rationale

Although glucose monitoring is important, it is not the priority. Insulin administration affects potassium levels more significantly in this scenario, and glucose level fluctuations are typically less life-threatening than potassium imbalances.

Choice C rationale

Monitoring intake and output is standard practice for managing clients with electrolyte imbalances. However, it does not directly address the primary concern of potassium level fluctuations caused by insulin administration.

Choice D rationale

A daily 12-lead electrocardiogram may provide useful information on the cardiac effects of electrolyte imbalances but is less immediate in detecting rapid potassium changes than frequent serum potassium measurements.

A. Consult with a nurse who shares the same religious beliefs. B. Research the religion on different social media platforms. C. Ask the client about individual care preferences. D. Explain that every client will receive the same high level of care.

Correct Answer is C

Explanation

Choice A rationale

Consulting with a nurse who shares the same religious beliefs may provide insight, but it may not fully address the client's unique care preferences and individual needs.

Choice B rationale

Researching the religion on social media platforms can offer information, but it is not a substitute for understanding the client's specific preferences and requirements.

Choice C rationale

Asking the client about individual care preferences is the best approach, ensuring that care is personalized and respectful of the client's religious beliefs, leading to better compliance and satisfaction.

Choice D rationale

Explaining that every client receives the same high level of care is important but does not address the client's specific religious concerns and preferences.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Correct Answer is C

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Scenario: A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. Exhibits The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown.

Arterial Blood Gas Laboratory Test

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.