The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?

Complete blood cell count (CBC) in AM.

Straight catheterization if unable to void.

Advance from clear liquids as tolerated.

Cefazolin 1 gram intravenously every 6 hours.

Answer and Explanation

The Correct Answer is D

A. A complete blood cell count (CBC) is important for monitoring but is not an immediate priority during the admission process.

B. This is a conditional order (PRN/as needed). The nurse must first assess the client's bladder (e.g., check for distention, monitor output) and allow time for spontaneous voiding to occur. It's not the first action, but a necessary intervention if a certain condition (inability to void) is met later.

C. Advancing from clear liquids as tolerated can be important for nutrition but does not address immediate postoperative concerns regarding urinary function.

D. Cefazolin is a broad-spectrum antibiotic commonly prescribed for surgical prophylaxis to prevent postoperative infections. The first priority after surgery is infection prevention, since the client is most vulnerable during the immediate postoperative period. Administering the first dose of the antibiotic promptly helps reduce the risk of surgical site infections (SSIs), which can lead to serious complications. The other prescriptions are important but not time-critical compared to initiating antibiotic therapy.

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Correct Answer is ["A","E"]

Explanation

A. A full pitcher of water is concerning as excessive fluid intake can exacerbate heart failure by causing fluid overload, leading to worsening edema and respiratory distress.

B. A saline lock is appropriate for maintaining venous access and does not pose immediate harm to the client.

C. A low sodium diet tray is appropriate for managing heart failure and is beneficial for this client.

D. A bedside commode positioned near the bed can facilitate safe toileting and is not harmful.

E. Lying in a supine position can increase venous return and exacerbate heart failure symptoms; the client may require a more elevated position to ease breathing and reduce cardiac workload.

A. Tomato juice and gluten free crackers. B. Dill pickles and black olives. C. Plain baked sweet potato. D. Canned chicken broth with barley.

Correct Answer is C

Explanation

A. Tomato juice may contain high sodium levels, which is not ideal for a hypertensive diet.

B. Dill pickles and black olives are typically high in sodium, which can exacerbate hypertension.

C. A plain baked sweet potato is low in sodium and high in potassium, making it a suitable choice for someone with hypertension.

D. Canned chicken broth often contains high levels of sodium, which is not recommended for hypertension management.

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The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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