Exhibits Here
The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.
Obtain a complete blood count.
Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery.
Administer Rh, D immune globulin prior to surgery.
Explain the surgical procedure to the client.
Verify consent form is signed by the client.
Assist with the administration of AB-positive blood products if needed.
Remind the client to be NPO prior to surgery.
Correct Answer : A,B,C,E,G
Based on the given information, the nurse should take the following actions in preparation for surgery:
- Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
- Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
- Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to
Rh-positive blood.
- Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
- Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.
The following actions are not indicated based on the given information:
- Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
- Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Let me show you how to swaddle and cuddle him, then you try.
The appropriate response for the nurse in this situation is to provide support and education to the new mother. Option B, "Let me show you how to swaddle and cuddle him, then you try," demonstrates a helpful and empowering approach.
I'll take him back to the nursery, so you can get some rest in (option A) is incorrect. This response dismisses the mother's concerns and suggests removing the baby from her care without addressing her need for guidance and support. It is important to encourage and assist the mother in learning how to care for her newborn rather than taking over the responsibility.
If I turn him on his side, maybe he'll go back to sleep in (option C) is incorrect. This response suggests a specific action without addressing the underlying concerns of the mother. It is important to provide guidance and reassurance rather than suggesting potential solutions without understanding the cause of the baby's crying.
Babies need to cry soon after they are born to develop their lungs in (option D) is incorrect. This response is not relevant to the mother's concerns and does not address her feelings of inadequacy. It is important to provide support and guidance in caring for the newborn rather than providing unrelated information.
Correct Answer is D
Explanation
Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.
Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.
Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence.
Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.
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