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.
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.
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Related Questions
Correct Answer is D
Explanation
A. Assessing for increasing fluid volume overload is not indicated with a rising serum sodium level; instead, it suggests correction of hyponatremia, a common complication of SIADH.
B. Withholding the next scheduled dose of treatment is not appropriate based solely on a rise in serum sodium level within the normal range.
C. Increasing neurologic checks may be necessary in severe cases of hyponatremia but is not directly indicated by a rise in serum sodium within the normal range.
D. Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
Correct Answer is []
Explanation
Potential condition: Retinopathy
Actions to take: Orient the client to the environment; Call for an ophthalmological exam
Parameters to monitor: Blood glucose; Visual acuity
Rationale:
Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.
The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.
Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.
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