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.

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Correct Answer is ["125"]

Explanation

To calculate the infusion rate in mL/hr, you would convert the total volume of lactated Ringer's IV from liters to milliliters (since there are 1,000 milliliters in a liter, 3 liters is equivalent to 3,000 milliliters) and then divide by the total number of hours over which the infusion is to be administered. In this case, 3,000 mL divided by 24 hours results in an infusion rate of 125 mL/hr.

A. Increase oxygen flow. B. Administer additional nebulizer treatment as ordered. C. Raise the head of the bed. D. Apply a nonrebreather oxygen mask. E. Provide client incentive spirometer and instruct on use. F. Take and monitor vital signs.

Correct Answer is ["A","B","C","D","F"]

Explanation

A. The patient’s oxygen saturation remains below the target of 94% despite initial oxygen therapy. Therefore, increasing the oxygen flow might be necessary to achieve better oxygenation.

B. Since the patient remains symptomatic with ongoing wheezes, administering another dose of the nebulizer treatment as ordered, since the prescription included PRN can help to further open the airways and alleviate wheezing.

C. Elevating the head of the bed can help improve lung expansion and ease the work of breathing, which is particularly beneficial in respiratory distress situations.

D. Switching to a nonrebreather mask may be appropriate if the patient’s oxygen saturation does not improve sufficiently with the current method of oxygen delivery. This type of mask can deliver a higher concentration of oxygen.

E. While incentive spirometry is generally used for preventing pulmonary complications (such as pneumonia or atelectasis) after surgery or in conditions where patients are likely to be immobile, it may not be immediately beneficial or a priority in the acute management of an asthma attack. The primary focus should be on stabilizing the patient’s respiratory status through medication and oxygen therapy. Thus, this option is less critical at this stage.

F. Continuous monitoring of vital signs is crucial in acute cases like this to assess the patient's response to interventions and detect any deterioration in the clinical status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)

Correct Answer is ["125"]

Explanation

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Correct Answer is ["A","B","C","D","F"]

Explanation

A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

Patient Data Exhibits Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

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.)

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.