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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

Elevating the head of the bed while sleeping is a recommended strategy for managing GERD (gastroesophageal reflux disease). By raising the head of the bed, gravity helps to prevent stomach acid from flowing back into the esophagus, reducing the likelihood of acid reflux and associated symptoms.

"You should eat three large meals and two snacks per day" is not recommended for GERD management. Instead, it is advised to have smaller, more frequent meals throughout the day to reduce the pressure on the stomach and minimize the likelihood of acid reflux.

"You should lay down for 1 hour following a meal" is not recommended for GERD management. It is advised to avoid lying down immediately after meals, as this can increase the risk of acid reflux. It is generally recommended to wait at least 2 to 3 hours before lying down.

"You should only drink 2 cups of coffee per day" is a specific recommendation related to caffeine intake, which can potentially trigger or worsen GERD symptoms in some individuals. However, this statement alone does not encompass the comprehensive dietary recommendations for managing GERD.

A. Coil the tubing on the bed above the collection bag B. Instruct the client to hold the drainage bag at waist height when ambulating C. Secure the tubing with adhesive tape to the lower abdomen D. Collect a sterile specimen from the urinary drainage bag

Correct Answer is ["C"]

Explanation

A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.

B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.

C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.

D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.

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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

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is ["C"]

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