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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While controlling blood pressure is important in managing cardiovascular disease, the specific outcome should reflect the target blood pressure goal of less than 140/80 mm Hg to reduce the risk of complications.
B. Encouraging physical activity is beneficial for cardiovascular health, but the outcome should focus on blood pressure management, which is more directly related to the client's reported symptoms of blurred vision.
C. Educating the client's family about signs and symptoms of cardiovascular disease is important for support, but it does not directly address the client's blurred vision or cardiovascular risk factors.
D. Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to ensure adequate control of blood pressure and reduce the risk of cardiovascular complications, including those that may contribute to blurred vision.
Correct Answer is C
Explanation
A. Fentanyl and hydromorphone are potent opioids often used for pain management, but they are not typically first-line medications for acute chest pain associated with suspected myocardial infarction.
B. Hydromorphone, like fentanyl, is an opioid analgesic primarily used for moderate to severe pain but is not the first choice for managing acute chest pain.
C. Morphine is the medication of choice for managing acute chest pain associated with myocardial infarction. It helps alleviate pain, reduce myocardial oxygen demand, and relieve anxiety.
D. Oxycodone is an opioid analgesic used for moderate to severe pain but is not typically indicated as first-line therapy for acute chest pain associated with myocardial infarction.
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