The nurse is preparing a client for surgery who was admitted to the emergency center 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 subcutaneously daily. What is the priority nursing action?

Have the client sign the surgical and transfusion permits.

Ensure that the potential for bleeding is explained to the client

Observe the heparin injections sites for signs of bruising.

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

Answer and Explanation

The Correct Answer is D

A. Have the client sign the surgical and transfusion permits:
While obtaining signed consent is important, the immediate concern is addressing the client's medication history, especially the use of heparin, which can contribute to bleeding.

B. Ensure that the potential for bleeding is explained to the client:
Education about the potential for bleeding is important, but the immediate action is to communicate the client's medication history to the healthcare provider for appropriate guidance.

C. Observe the heparin injection sites for signs of bruising:
Monitoring for bruising at injection sites is a consideration, but it is not the priority when the client is actively bleeding from an open fracture.

D. Notify the healthcare provider of the client's medication history:
This is the correct answer. Heparin is an anticoagulant, and its use can increase the risk of bleeding during surgery. The healthcare provider needs to be informed of the client's current medication history to make decisions regarding the timing and management of heparin therapy in the perioperative period.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Keep the room at a comfortable temperature:
While maintaining a comfortable room temperature is important for the overall well-being of the client, it is not the most essential intervention during a seizure. The priority during a seizure is to ensure the client's safety, particularly focusing on airway management.

B. Ensure oral suction is available:
This is the most essential intervention. During a seizure, the client may produce excessive saliva, and having oral suction readily available helps prevent airway obstruction and ensures a clear airway. It is crucial for the safety and well-being of the client.

C. Provide frequent mouth care:
Mouth care is important for the overall hygiene of the unconscious client, but it may not be the most immediate priority during a seizure. The focus during a seizure is on preventing complications such as aspiration or airway obstruction.

D. Maintain the client in a semi-Fowler's position:
Positioning is important for the comfort and safety of the unconscious client, but maintaining a semi-Fowler's position may not be the primary concern during an active seizure. The immediate focus is on airway management and preventing injury.

A. Platelet count 40,000 x10/μL (40.000 x109/L). B. White blood cells 9,000/μL (9x109/L) C. Hematocrit 38% (0.38). D. Hemoglobin 12 g/dL (120 g/L).

Correct Answer is A

Explanation

A. Platelet count 40,000 x10/μL (40.000 x109/L):
This is the correct answer. A platelet count of 40,000 x10/μL is significantly below the normal range (usually around 150,000 to 450,000/μL). Low platelet count (thrombocytopenia) can increase the risk of bleeding during and after a surgical procedure. The healthcare provider should be alerted to assess the risk and determine the appropriate management.

B. White blood cells 9,000/μL (9x109/L):
The white blood cell count is within the normal range, and it is not a significant concern for a vertebroplasty procedure.

C. Hematocrit 38% (0.38):
The hematocrit level is within the normal range and is not a significant concern for a vertebroplasty procedure.

D. Hemoglobin 12 g/dL (120 g/L):
The hemoglobin level is within the normal range and is not a significant concern for a vertebroplasty procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

Correct Answer is B

Explanation

The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse alert the healthcare provider of prior to the procedure?

Correct Answer is A

Explanation

Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide?

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?