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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Taking the client to the bathroom after a preoperative injection may be unsafe because many preoperative medications can cause sedation or dizziness, increasing the risk of falls.
B. Verification of the surgical site should occur before administration of preoperative medications, as the client may be sedated and unable to participate accurately afterward.
C. Teaching deep breathing and coughing exercises is most effective before sedation, when the client is alert and able to learn and follow instructions.
D. Raising the side rails on the bed is a priority safety measure after administering preoperative sedatives, as it helps prevent falls and injury while the client is drowsy or unsteady.
Correct Answer is B
Explanation
A. Serum calcium levels are not directly indicative of hypervolemia.
B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.
C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.
D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.
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