A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?

Ensure that there is an incentive spirometer ready for when the patient gets to the PACU to help prevent atelectasis.

Provide preoperative teaching about preventing blood clots after surgery.

Report to the provider that the patient has allergies to sardines.

Administer the ordered preoperative intravenous antibiotic.

Answer and Explanation

The Correct Answer is D

A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.

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Correct Answer is A

Explanation

A. A potassium level of 3.3 mEq/L indicates hypokalemia, which can lead to cardiac dysrhythmias due to the role of potassium in maintaining normal cardiac conduction and muscle contraction. Monitoring the client’s heart rhythm is crucial.
B. Neurogenic shock is not a complication of hypokalemia. It is typically caused by spinal cord injury or central nervous system damage, not electrolyte imbalances.
C. Hypoglycemia is not directly associated with hypokalemia or furosemide use. Furosemide primarily affects fluid and electrolyte balance, not glucose regulation.
D. While severe hypokalemia can cause neuromuscular issues, seizures are more commonly associated with conditions like hyponatremia or hypocalcemia, not hypokalemia.

A. Administer furosemide to the client. B. Educate the client that oral fluids are not necessary. C. Monitor the client's weight once a week. D. Monitor the client's IV site and infusion.

Correct Answer is D

Explanation

A. Administering furosemide (a diuretic) would worsen dehydration and is contraindicated in this scenario. The goal is to rehydrate the client, not to promote fluid loss.
B. Educating the client that oral fluids are not necessary is incorrect. Oral fluids are important for rehydration, and the client should be encouraged to drink fluids unless contraindicated.
C. Monitoring the client's weight once a week is not sufficient for assessing dehydration status. More frequent monitoring is needed to assess the effectiveness of treatment.
D. Monitoring the client's IV site and infusion is essential to ensure that the IV is patent, the fluid is being infused properly, and there are no complications such as infiltration or infection. This is a key aspect of nursing care for clients receiving IV fluids.

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A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

Correct Answer is A

Explanation

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate?

The nurse is caring for a pediatric client who experienced a "greenstick" fracture. The client's mother asks the nurse what it means to have this type of fracture. Which of the following statements should the nurse make?

Which assessment finding is most indicative of hypernatremia?

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Which of the following is a potential complication for a client whose potassium level is 6.5 mEq/L?

A client with hypovolemia is at risk for orthostatic hypotension. Which of the following interventions should the nurse implement in this client?

The nurse should explain that which of the following medications puts a client at risk for developing hyperkalemia?