A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

A. "The oral medication you will take after this IV will dissolve the clot": This statement is incorrect. While anticoagulants like warfarin or direct oral anticoagulants (DOACs) may be prescribed to prevent the formation of new clots or to treat existing clots, heparin, whether administered intravenously or subcutaneously, is not typically used to dissolve existing clots.
B. "A pharmacist is the person to answer that question": This response deflects the client's question and does not provide useful information. While pharmacists are knowledgeable about medications, nurses are responsible for educating clients about their treatments and should be able to provide accurate information regarding heparin therapy.
C. "Heparin does not dissolve clots. It stops new clots from forming": This is the correct response. Heparin is an anticoagulant medication that works by inhibiting the formation of new clots rather than dissolving existing ones. It does so by inhibiting the activity of clotting factors in the blood, thus preventing the clot from enlarging or new clots from forming.
D. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level": While this statement provides information about the time required for heparin to achieve a therapeutic effect, it does not address the client's specific question about clot dissolution. Heparin's anticoagulant effects occur rapidly, but its primary action is prevention rather than dissolution of existing clots.