Try Naxlex NCLEX-RN (Free-Trial)

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","D"]

Explanation

Assist the client with a bath: The client is independently transferring out of bed and ambulating in the hallway. Since they are managing personal mobility well, there is no immediate need for assistance with bathing, and this does not address the client’s most pressing issues.
Encourage oral fluid intake: The client is experiencing hard, painful bowel movements and abdominal cramping, which are signs of constipation. Increased oral fluid intake can help soften stool and promote more regular bowel movements, making this a supportive and appropriate intervention.
Irrigate indwelling catheter with 500 mL of fluid: The client is voiding 100 mL/hr of pink urine, which is a normal finding in the early postoperative period and does not suggest catheter obstruction. Therefore, irrigation is not indicated and could introduce infection unnecessarily.
Administer an enema: The client reports painful, incomplete bowel elimination and abdominal cramping, which may indicate constipation or fecal impaction. Administering an enema is an appropriate intervention to relieve discomfort and promote bowel evacuation.
Encourage prolonged dangling before ambulation: The client is already ambulating independently in the hallway, indicating they are tolerating activity well. There is no evidence of orthostatic intolerance, so prolonged dangling is not necessary.

A. "I will call the provider after taking one dose of nitroglycerin." B. "I will hold my breath and bear down." C. "I will stop what I am doing and lie down." D. "I will take two 325 milligram aspirin tablets at the same time.”

Correct Answer is C

Explanation

Nitroglycerin is a common medication used to relieve chest pain associated with angina. However, if the client is experiencing ongoing chest pain, it is important to follow the prescribed instructions for nitroglycerin administration, which may involve taking additional doses if needed, as instructed by the healthcare provider. Calling the provider after taking one dose may not address ongoing chest pain adequately.

This action, known as the Valsalva maneuver, is not recommended for managing chest pain associated with stable angina. The Valsalva maneuver involves forcibly exhaling while keeping the mouth and nose closed, which can temporarily decrease blood flow to the heart and may exacerbate chest pain.

Chewing two aspirin tablets is recommended for acute myocardial infarction to inhibit platelet aggregation, but in stable angina the immediate priority is rest and nitroglycerin.

I will stop what I am doing and lie down.” This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Exhibits Here The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Select the 2 actions the nurse should prepare to take for the client.

Correct Answer is ["B","D"]

Explanation

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

Exhibits Here

The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.