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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

Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.

While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.

The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.

The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.

A. 8 oz chopped hard-boiled egg B. 8 oz brown rice C. 8 oz fruit yogurt D. 8 oz raw spinach

Correct Answer is A

Explanation

Explanation

A.8 oz chopped hard-boiled egg

Eggs are considered a complete protein source, meaning they contain all essential amino acids that the body needs. They are an excellent source of high-quality protein and provide essential nutrients. Chopped hard-boiled eggs, in particular, can be easily added to salads, sandwiches, or consumed on their own.

8 oz brown rice in (option B) is incorrect because brown rice is a healthy carbohydrate source, it is not a significant source of protein.

8 oz fruit yogurt in (option C) is incorrect because fruit yogurt may contain some protein, but the protein content is generally lower compared to other sources such as eggs.

8 oz raw spinach in (option D) is incorrect because spinach is a nutrient-rich vegetable, it is not a significant source of protein.

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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

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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