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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

A.

Obtain a complete blood count.

B.

Prepare client for insertion of 18-gauge peripheral IV prior to surgery.

C.

Administer Rh, D immune globulin prior to surgery.

D.

Explain the surgical procedure to the client.

E.

Verify consent form is signed by the client.

F.

Assist with administration of AB positive blood products if needed.

G.

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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Related Questions

Correct Answer is C

Explanation

Correct answer: C

A.Opening the dampers of fireplaces: This instruction is not appropriate during an outdoor chemical disaster. Opening the dampers of fireplaces can allow contaminated air from outside to enter the home, increasing the exposure to hazardous substances. It is best to avoid introducing outdoor air into the home during such incidents.

B. Turning on ceiling fans and air conditioners: This instruction is also not recommended during an outdoor chemical disaster. Turning on fans and air conditioners can potentially circulate contaminated air within the home, leading to increased exposure. It is best to turn off fans and air conditioners during such incidents and focus on evacuating the area.

C. Covering heat registers with plastic and tape: Covering heat registers with plastic and tape would help seal off potential entry points for contaminated air, reducing the risk of indoor contamination.

D.In the case of a nearby outdoor chemical disaster, it is usually safer to stay indoors and seal the home rather than exit, as going outside could increase exposure to the harmful chemicals.

Correct Answer is C

Explanation

The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.

Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.

Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.

Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.

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