The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Cefazolin 1 gram IV every 6 hours.

Complete blood cell count (CBC) in AM.

Advance from clear liquids as tolerated.

Straight catheterization if unable to void.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

A. Apical heart rate. B. Pulse pressure. C. Level of consciousness. D. Blood pressure.

Correct Answer is D

Explanation

Choice A reason: The apical heart rate is important for other assessments but does not directly assess for orthostatic hypotension.

Choice B reason: Pulse pressure is not specifically related to orthostatic hypotension assessment.

Choice C reason: Level of consciousness can be affected by orthostatic hypotension but is not the primary assessment.

Choice D reason: Blood pressure should be measured in both lying and standing positions to assess for orthostatic hypotension.

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The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Correct Answer is D

Explanation

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