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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Notifying the healthcare provider about allergies to iodine or shellfish is crucial, as IVP contrast agents often contain iodine, and allergic reactions can occur. This is a safety measure that can prevent adverse reactions.
B. While keeping the legs straight may be necessary during the procedure, there is no requirement for them to be kept straight for 6 to 8 hours afterward.
C. While hydration is important, the focus should be on hydration after the procedure to help flush out the contrast material rather than specifically drinking large volumes before the procedure.
D. Inserting an indwelling urinary catheter is not routinely required for IVP unless specified by the healthcare provider; preparation usually focuses on the client’s hydration and allergy history.
Correct Answer is D
Explanation
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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