The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3.
The nurse is preparing the client for surgery. Which of the following actions should the nurse take. Select all that apply.
Assist with administration of AB positive blood products if needed.
Prepare client for insertion of 18-gauge peripheral IV prior to surgery.
Administer Rh, D immune globin prior to surgery.
Obtain a complete blood count.
Explain the surgical procedure to the client.
Remind client to be NPO prior to surgery.
Verify consent form is signed by the client.
Correct Answer : B,C,D,F,G
- Prepare client for insertion of 18-gauge peripheral IV prior to surgery: A large-bore IV catheter, such as an 18-gauge, is necessary before surgery to ensure rapid administration of fluids, medications, or blood products if needed during the procedure. It is a measure to support hemodynamic stability during anesthesia and surgery.
- Administer Rh, D immune globin prior to surgery: The client's blood type is B negative. Because an ectopic pregnancy involves fetal tissue, and there's a potential for fetal-maternal blood mixing during the surgery, administering Rh(D) immune globulin (RhoGAM) is crucial to prevent Rh sensitization in Rh-negative women who may be carrying an Rh-positive fetus. This is typically given within 72 hours of a potential sensitizing event.
- Obtain a complete blood count: A CBC is critical to assess hemoglobin, hematocrit, and platelet levels before surgery. This helps the healthcare team anticipate the risk of bleeding and determine if transfusions might be necessary during or after the laparoscopic procedure.
- Explain the surgical procedure to the client: Explaining the surgical procedure is the provider's responsibility, not the nurse's role. The nurse can reinforce teaching and answer basic questions but should not be the primary person explaining the procedure or obtaining informed consent.
- Remind client to be NPO prior to surgery: Maintaining NPO status is essential to reduce the risk of aspiration during anesthesia. The client should avoid eating or drinking for a specified time before surgery, following the facility's preoperative protocol.
- Verify consent form is signed by the client: Verifying that the informed consent form is properly signed is a crucial nursing responsibility before surgery. It ensures legal compliance and confirms that the client has been informed about the procedure, risks, and alternatives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Changing a sterile dressing for a client who is postoperative: Changing a sterile dressing requires the use of sterile technique and nursing judgment, making it a task that must be performed by a licensed nurse, not delegated to assistive personnel.
B. Performing a gastrostomy feeding on a stable client: While assistive personnel can assist with feeding in general, administering a gastrostomy feeding requires specific assessment and verification of tube placement, which must be done by a licensed nurse.
C. Observing the patency of an intravenous catheter on a stable client: Observing and assessing IV catheter patency is a nursing responsibility. It requires assessment skills and cannot be delegated to assistive personnel.
D. Providing postmortem care to a client: Providing postmortem care, such as bathing, positioning, and preparing the body, is a task that can be safely delegated to assistive personnel, following proper facility protocols and respectful handling of the deceased.
Correct Answer is A
Explanation
A. Rigid expectations of behavior: Perpetrators of child abuse often have unrealistic and rigid expectations of children’s behavior. When children do not meet these expectations, it can lead to frustration, anger, and abusive responses from the caregiver.
B. Self-blame for financial problems: While financial stress can be a risk factor for family dysfunction, self-blame alone is not a recognized direct characteristic of child abuse perpetrators. Abusive behavior is more often linked to blaming others and lack of coping skills.
C. Laissez-faire leadership style: A laissez-faire leadership style involves being hands-off or permissive, which is not typically associated with abusive behaviors. Abusers are often controlling and overly strict, not permissive.
D. High self-esteem: High self-esteem is generally associated with healthy interpersonal behavior. Low self-esteem, poor coping mechanisms, and unresolved personal trauma are more commonly seen in those who commit child abuse.
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