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 A
Explanation
A. Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is essential in the immediate management of a client with sudden, severe headache and neurological deficits suggestive of stroke. Time- sensitive interventions, such as IV fibrinolytic therapy, may be indicated if the client meets criteria for treatment.
B. Administering aspirin to prevent further clot formation and platelet clumping is contraindicated in the acute management of a suspected stroke until hemorrhagic stroke is ruled out.
C. Verifying prescribed laboratory tests include prothrombin time and platelet count is important for assessing coagulation status, but it is not the immediate intervention needed in this situation.
D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority intervention in the acute management of a suspected stroke.
Correct Answer is C
Explanation
A. Bronze pigmentation is not typically associated with compromised peripheral arterial circulation but may be seen in conditions like hemochromatosis.
B. Lower leg edema is more commonly associated with venous insufficiency rather than compromised arterial circulation.
C. Uneven hair distribution, such as decreased hair growth on the lower extremity, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.
D. Bounding peripheral pulse is not typically associated with compromised peripheral arterial circulation but may indicate increased stroke volume or arterial stiffness.
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