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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.

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Correct Answer is C

Explanation

Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired blood clotting and an increased risk of bleeding. The use of a firm-bristled toothbrush can cause trauma to the gums and oral tissues, increasing the risk of bleeding in someone with thrombocytopenia. It is recommended for individuals with thrombocytopenia to use a soft-bristled toothbrush to minimize the risk of oral bleeding.

Wearing a face mask around others, increased intake of green, leafy vegetables, and getting an adequate amount of sleep does not directly increase the client's risk for injury in the context of thrombocytopenia. These practices are generally beneficial for overall health and well-being.

A. Apply suction while inserting the catheter. B. Apply intermittent suction for 30 seconds. C. Wait 1 min between suctioning attempts. D. Insert the catheter 10 cm (4 in).

Correct Answer is C

Explanation

A.Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.

B.Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.

C.Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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Exhibits Here

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