The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

Have the client sign the surgical and transfusion permits.

Notify the healthcare provider of the client's medication history.

Ensure that the potential for bleeding is explained to the client.

Observe the heparin injections sites for signs of bruising.

Answer and Explanation

The Correct Answer is B

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.

B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.

C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.

D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.

Correct Answer is ["0.4"]

Explanation

To determine the correct dosage, the nurse needs to perform a calculation using the information provided. The prescription is for 200,000 units of penicillin, and the available vial concentration is 500,000 units per mL.

To find out how many mLs to administer, the nurse would divide the prescribed units by the concentration of units per mL. This is calculated as 200,000 units divided by 500,000 units/mL, which equals 0.4 mL.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

Correct Answer is A

Explanation

The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL. How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.4"]

Explanation

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.