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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Correct Answer is A

Explanation

A. Move the client to a private room, keep the door closed, and initiate droplet precautions:
This is the correct answer. Given the client's symptoms and potential exposure to COVID-19, it is important to take infection control measures. Placing the client in a private room, keeping the door closed, and initiating droplet precautions help prevent the potential spread of the virus.

B. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results:
Antiviral medications are typically prescribed based on confirmed COVID-19 test results and the severity of symptoms. Starting an intravenous infusion at this stage, before test results are available, is premature and not indicated.

C. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with the patient:
While it is important for family members to monitor for symptoms, the immediate concern is the isolation and testing of the symptomatic client. Contact tracing may follow, but infection control measures for the client are the priority.

D. Assist the client to recall everyone possibly exposed since onset of symptoms:
While contact tracing is important, the immediate action is to isolate the client and initiate precautions. Contact tracing can be done as part of a broader public health response but is not the initial step.

A. Eat a diet high in carotene. B. Wear prescription glasses. C. Avoid frequent eye pressure measurements. D. Maintain prescribed eye drop regimen

Correct Answer is D

Explanation

A. Eat a diet high in carotene:
While a healthy diet is important for overall well-being, there is no evidence to suggest that a diet high in carotene specifically prevents or treats glaucoma. The focus in glaucoma management is on intraocular pressure control.

B. Wear prescription glasses:
Prescription glasses may be beneficial for addressing refractive errors, but they do not specifically address the management of glaucoma. The client's concern about driving through a tunnel is more likely related to changes in peripheral vision associated with glaucoma.

C. Avoid frequent eye pressure measurements:
This is not the most important instruction. Monitoring intraocular pressure is a crucial aspect of glaucoma management, and the frequency of measurements is determined by the healthcare provider. Regular monitoring helps assess the effectiveness of treatment and disease progression.

D. Maintain the prescribed eye drop regimen:
This is the correct answer. The most important instruction for the client is to adhere to the prescribed eye drop regimen. Medications, often in the form of eye drops, are commonly used to lower intraocular pressure and manage glaucoma. Consistent use of prescribed medications is critical for controlling the condition and preventing further vision loss.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

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?

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?