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 A
Explanation
Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. When providing discharge teaching to the caregiver of a client with dependent personality disorder, it is important to promote the client's independence and self-empowerment. Encouraging the client to be assertive is an appropriate instruction because it promotes the development of self-advocacy skills and assertiveness, which can help the client gain confidence and reduce dependency on others.
limiting the client's social interactions in (option B) is incorrect because it, would not be an appropriate instruction. Restricting social interactions may further reinforce the client's dependency and hinder their ability to develop social skills and relationships.
maintaining a verbal no-harm contract with the client in (option C) is incorrect because it, is not specifically related to the management of dependent personality disorder. No-harm contracts are more commonly used in the context of managing self-harm or suicidal ideation, which may or may not be present in individuals with dependent personality disorder.
assuming responsibility for making the client's decisions in (option D) is incorrect because it, would further enable the client's dependency and undermine their autonomy. It is important to encourage the client to make their own decisions and take responsibility for their actions, within their capabilities.
Correct Answer is ["A","C","D"]
Explanation
A.The client's complaint of upper chest discomfort and coughing up thick clear sputum suggests a potential respiratory issue. Checking oxygen saturation is crucial to assess for possible respiratory distress or hypoxia.
B.Tremors are a chronic symptom associated with Parkinson's disease in this client. While monitoring tremors is important for assessing Parkinson's disease management, they are not an acute issue requiring immediate follow-up in this scenario.
C.Coughing up thick clear sputum and upper chest discomfort indicate potential respiratory distress or infection. Monitoring the respiratory rate helps assess the severity of respiratory distress or compromise.
D.Heart rate is a vital sign that can indicate cardiovascular status and response to the client's reported symptoms of feeling bad. Elevated heart rate may indicate stress, pain, or cardiac involvement.
E.The client is reported as alert and oriented to self. While changes in level of consciousness are always important to monitor, the client's current alert and oriented state suggests no immediate acute change.
F.Chronic health conditions such as Parkinson's disease and anxiety are part of the client's history but are not acute findings that require immediate follow-up compared to the acute symptoms of upper chest discomfort and respiratory distress reported.
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