Exhibits

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?

Initiate an IV access for the client.

Administer pain medication to the client.

Send the client to radiology for a CT scan.

Insert an NG tube for the client.

Answer and Explanation

The Correct Answer is A

A.   Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B.   Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C.   Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D.   Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.

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Correct Answer is A

Explanation

A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.

B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.

C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.

D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.

A. Cleanses the wound with povidone-iodine on cotton balls B. Administers PO analgesia 20 min prior to irrigation C. Warms the irrigation solution in the microwave oven prior to application D. Irrigates the wound from the top to the bottom

Correct Answer is D

Explanation

A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.

B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.

C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.

D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.

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Exhibits A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?

Correct Answer is D

Explanation

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Exhibits

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?