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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

Explanation

Correct:

A. Creating a stimulating environment helps engage the client and can reduce restlessness and agitation. This can include activities, social interactions, and sensory stimulation tailored to the individual's preferences.

C. Clients with Alzheimer's disease may become overwhelmed and have difficulty making decisions when presented with too many options. By limiting choices, caregivers can help reduce confusion and frustration for the client.

D. Clients with Alzheimer's disease may experience memory impairment and difficulty with orientation. Using written signs can help them navigate their surroundings and locate essential areas, such as the bathroom. Clear and simple signs can be helpful for maintaining independence and minimizing confusion.

incorrect:

B. Confrontation, which involves challenging or arguing with the client, can escalate agitation and distress. Instead, caregivers should use techniques such as redirection, validation, and providing a calm and supportive environment to manage challenging behaviors associated with Alzheimer's disease.

A. Verify the amount of TPN solution the client is receiving every 4 hr. B. Prepare the client for a chest x-ray to verify catheter placement. C. Use clean technique when changing the catheter dressing. D. Place the client in Sims' position for catheter insertion.

Correct Answer is B

Explanation

When a central venous catheter (CVC) is inserted, it is essential to confirm proper catheter placement to ensure safe and effective administration of TPN and other medications. A chest x-ray is the gold standard method to verify the correct positioning of the CVC tip. It helps determine if the catheter is appropriately positioned in the superior vena cava or another desired location, which minimizes the risk of complications such as pneumothorax or improper medication delivery.

The other options listed are not appropriate actions for the nurse to take in this situation:

Verifying the amount of TPN solution the client is receiving every 4 hours is a task related to ongoing monitoring of TPN administration, but it is not directly related to the preparation of the client for CVC insertion.
Using clean technique when changing the catheter dressing is not appropriate for CVC insertion. Sterile technique is required during the insertion of a CVC to minimize the risk of infection.
Placing the client in Sims' position is not the appropriate position for CVC insertion. The client is typically placed in a supine or Trendelenburg position during the procedure to facilitate access to the central venous system.

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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 assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

Correct Answer is ["A","C","D"]

Explanation

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Correct Answer is B

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