A nurse is preparing a client for surgery and has just administered the preoperative injection.
Which of the following actions should the nurse take?
Take the client to the bathroom to void.
Ask the client to verify the surgical site.
Review deep breathing and coughing exercises.
Raise the side rails on the bed.
None
None
The Correct Answer is D
A. Taking the client to the bathroom after administering a preoperative sedative increases the risk of falls.
B. Surgical site verification should be completed before administering the preoperative medication.
C. Teaching should be done before giving the medication, as the sedative may impair learning and recall.
D. Raising the side rails helps ensure client safety by preventing falls after the medication has been administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
Correct Answer is B
Explanation
A. Crepitus is a finding associated with subcutaneous emphysema or gas accumulation under the skin, typically not directly related to right ventricular heart failure.
B. Right ventricular heart failure can lead to increased pressure in the pulmonary artery, resulting in symptoms such as dyspnea, fatigue, and possibly right-sided heart murmurs.
C. Hepatosplenomegaly (enlargement of the liver and spleen) is more commonly associated with conditions such as liver cirrhosis, not specifically right ventricular heart failure.
D. Confusion is not typically associated with right ventricular heart failure unless there are complications such as hypoxemia or impaired cerebral perfusion.
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