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Exhibits

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 client for insertion of 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 administration of AB positive blood products if needed.

Remind 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

Explanation:

Bleach is an effective disinfectant for blood spills and is recommended by healthcare guidelines for its ability to kill a broad range of microorganisms, including bloodborne pathogens such as human immunodeficiency virus (HIV). To prepare a bleach solution, the nurse can mix 1-part bleach with 10 parts water. This diluted bleach solution can be used to clean and disinfect the overbed table surfaces that have been contaminated with blood.

A- Chlorhexidine is an antiseptic commonly used for skin preparation before invasive procedures, but it is not the ideal choice for disinfecting surfaces or objects after a blood spill.

B- Isopropyl alcohol is effective for disinfecting small surfaces, but it may not be as effective as bleach for blood spills, particularly in the context of bloodborne pathogens like HIV.

D- Hydrogen peroxide can be used as a disinfectant, but it may not be as effective as bleach in eliminating bloodborne pathogens from surfaces.

A. "The client's partner visited earlier today for 2 hours." B. "The client received the prescribed antibiotic every 8 hours." C. "The client reports pain is reduced when he is positioned on his side." D. "The client's mother died 4 years ago from breast cancer."

Correct Answer is ["C"]

Explanation

A.While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.

B. The client received the prescribed antibiotic every 8 hours: This is important information, but it is typically documented in the medication administration record (MAR) and does not need to be included in the verbal report unless there were issues or changes related to the medication.

C. The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

D. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

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Exhibits 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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Explanation

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Exhibits

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