A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?
"l stopped taking aspirin last week."
"l did not put my contact lenses in this morning."
"l took my blood pressure meds with a sip of water."
"l had a cough and runny nose a couple days ago."
The Correct Answer is D
A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.
B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.
C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.
D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Ensuring that the client and their family are kept informed about the client's care
Rationale:
A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.
B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.
C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.
D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.
Correct Answer is B
Explanation
A. "You can have 2 to 3 cups of coffee throughout the day": Caffeine consumption can exacerbate tinnitus symptoms in some individuals. Therefore, advising the client to limit caffeine intake, rather than specifying a quantity, would be more appropriate.
B. "You should practice deep breathing exercises": Deep breathing exercises and relaxation techniques can help reduce stress and anxiety, which may contribute to tinnitus symptoms. Stress management strategies can be beneficial in managing tinnitus-related distress.
C. "You can use at least 2,300 mg of sodium daily": High sodium intake may exacerbate tinnitus symptoms in some individuals. Advising the client to limit sodium intake would be more appropriate to potentially alleviate symptoms.
D. "You should avoid exercising": Regular exercise is generally beneficial for overall health and well-being, including stress reduction, which can help manage tinnitus symptoms. Therefore, advising the client to avoid exercising is not appropriate.
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