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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 B

Explanation

The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.

"The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.

"What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.

"Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.

A. Encourage the family to be with the child during mealtimes B. Obtain the child's dietary history C. Offer the child nutritious snacks between meals D. Instruct the family to praise the child when they eat

Correct Answer is B

Explanation

Correct answer: B

A.Family presence can provide comfort and support to the toddler, making mealtimes a more positive experience. It can also encourage the child to eat more by setting a good example. However, without first understanding the child's dietary habits and possible issues, this intervention might not address the root cause of the poor intake.

B.The nurse’sfirst actionin caring for a toddler with poor dietary intake should be toobtain the child’s dietary history. Understanding the child’s current eating habits, preferences, and any potential barriers to adequate nutrition is essential for planning appropriate interventions. Once the dietary history is obtained, the nurse can tailor further actions based on the specific needs of the child.

C.Offering nutritious snacks can help increase the child's overall calorie and nutrient intake, which is particularly important if the child has a low appetite during regular meals. Nevertheless, this step should follow the assessment of the child's dietary history to ensure that the snacks offered are appropriate and to avoid potential allergies or intolerances.

D.Positive reinforcement can encourage healthy eating behaviors and make mealtime a more enjoyable experience for the child. Praising the child can motivate them to eat more. However, this should be done after understanding the child's eating patterns and preferences to ensure that the praise is given in a context that promotes effective and lasting change.

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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

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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