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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired blood clotting and an increased risk of bleeding. The use of a firm-bristled toothbrush can cause trauma to the gums and oral tissues, increasing the risk of bleeding in someone with thrombocytopenia. It is recommended for individuals with thrombocytopenia to use a soft-bristled toothbrush to minimize the risk of oral bleeding.

Wearing a face mask around others, increased intake of green, leafy vegetables, and getting an adequate amount of sleep do not directly increase the client's risk for injury in the context of thrombocytopenia. These practices are generally beneficial for overall health and well-being.

A. Avoid discussing the client's fears. B. Offer the client several choices at mealtimes. C. Remind the client of the day and time often. D. Alternate daily caregivers.

Correct Answer is C

Explanation

Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.

Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.

Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.

Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.

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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 collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

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A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

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A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

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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