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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

36-year-old client who is gravida 5, para 5, transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine just prior to delivery. Her spouse was at the bedside for delivery and appeared supportive. Blood type A+. Estimated blood loss was 600 ml. after delivery.

Rationale:

Gravida 5, Para 5 (G5P5): Having multiple pregnancies can increase the risk of uterine atony and hemorrhage after delivery. Each subsequent pregnancy may carry a higher risk for complications.

Prolonged Labor (25 hours): Prolonged labor is associated with increased uterine fatigue and can lead to uterine atony, which is a primary cause of PPH.

Delivery of a 9 lb 1 oz (4.1 kg): Macrosomia can lead to complications during birth, such as maternal and/or fetal trauma, which in turn may increase the likelihood of PPH.

Use of Forceps: The use of forceps during delivery can lead to trauma and lacerations, which may contribute to increased bleeding, especially with a 4th degree laceration.

4th Degree Laceration: This type of laceration extends through the anal sphincter and can lead to significant bleeding. It also increases the risk of infection and other complications.

Estimated Blood Loss of 600 mL: While this is within the normal range for delivery, it may be concerning in the context of the other risk factors and warrants careful monitoring for additional bleeding.

A. A resting respiratory rate of 35 breaths/min. B. Flaring of the nares. C. Diaphragmatic respirations. D. Bilateral bronchial breath sounds.

Correct Answer is B

Explanation

A. A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not indicate distress.

B. Flaring of the nares is a sign of respiratory distress, indicating increased work of breathing and the infant's effort to obtain more oxygen.

C. Diaphragmatic respirations are common in infants and do not necessarily indicate distress unless accompanied by other signs.

D. Bilateral bronchial breath sounds can be normal and do not specifically indicate acute respiratory distress.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is ["A","B","C","D"]

Explanation

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress?

Correct Answer is B

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address . In addition, he will need interventions to prevent .

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?