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. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.
B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.
C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.
D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.
Correct Answer is A
Explanation
A. Discontinue use of electronics 30 min before bedtime: The use of electronics before bedtime can disrupt the body's natural sleep cycle by suppressing melatonin production. Stopping electronic use at least 30 minutes before bed promotes relaxation and better sleep quality.
B. Drink a cup of coffee 1 hr before bedtime: Caffeine is a stimulant that can interfere with falling asleep and maintaining deep sleep. Consuming coffee close to bedtime would likely worsen sleep disturbances rather than help.
C. Consume a meal 1 hr before bedtime: Eating a large meal close to bedtime can cause discomfort, indigestion, and difficulty falling asleep. Light snacks are acceptable, but heavy meals should be avoided before sleeping.
D. Exercise 1 hr before bedtime: Vigorous exercise shortly before bedtime can increase adrenaline and body temperature, making it harder to fall asleep. Exercise is better scheduled earlier in the day to support restful sleep.
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