The nurse is planning preoperative care for a client who has a fractured wrist. Which of the following should the nurse include in the client's plan of care?
Bathroom privileges after premedication
Drink 8 oz of water
Preoperative diazepam 30 minutes before surgery
Enema administration
The Correct Answer is C
Choice A reason:
Bathroom privileges after premedication are not typically restricted unless the premedication impairs the client's ability to ambulate safely. However, it is important to ensure that the client does not fall or injure themselves due to the effects of the medication.
Choice B reason:
Drinking 8 oz of water is generally not advised immediately before surgery due to the risk of aspiration during anesthesia. Clients are usually instructed to fast, which includes not drinking any liquids, for a certain period before surgery.
Choice C reason:
Preoperative diazepam may be administered 30 minutes before surgery to help reduce anxiety and induce sedation. Diazepam is a benzodiazepine that can calm the client and facilitate a smoother induction of anesthesia.
Choice D reason:
Enema administration is not a standard preoperative procedure for a client undergoing a cholecystectomy unless there is a specific indication. The primary focus is on preventing infection and managing pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A 10 mm wheal is not indicative of TB infection. A wheal is a raised, often itchy area of skin that usually signifies an allergic reaction, not an infection. The TST looks for induration, which is a firm swelling, as a sign of TB infection.
Choice B Reason:
A 5 mm induration is considered positive in certain high-risk groups, such as people living with HIV, recent contacts of TB patients, or those with a history of organ transplants. For individuals without these risk factors, a 5 mm induration is not considered a positive result.
Choice C Reason:
A 15 mm induration is considered a positive TST result for individuals with no known risk factors for TB. This indicates that the person's immune system has reacted to the tuberculin purified protein derivative (PPD) injected under the skin, suggesting exposure to TB bacteria.
Choice D Reason:
Erythema, or redness of the skin, is not measured when interpreting TST results. The test measures induration, which is a palpable, raised, hardened area or swelling. Therefore, a 4 mm erythema does not indicate TB infection.
Correct Answer is B
Explanation
Choice A reason:
Placing the leg under a heat lamp every 3 hours is not recommended for the treatment of cellulitis. Heat lamps can cause burns and excessive drying of the skin, which may worsen the condition.
Choice B reason:
Wrapping a warm, wet towel around the affected area is a safe and effective way to apply heat therapy for cellulitis. It can help improve blood flow and relieve discomfort without the risk of burns associated with dry heat sources.
Choice C reason:
Using a heating pad directly on the skin, especially when lying down, can increase the risk of burns and is not recommended for treating cellulitis. Heating pads can provide uneven heat and may exacerbate swelling and inflammation.
Choice D reason:
Soaking the leg in water is not typically advised for cellulitis, especially if there are open wounds or breaks in the skin. Immersion in water can introduce new bacteria to the affected area and potentially worsen the infection.
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