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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jogs more frequently than usual daily routine:
Exercise, including jogging, is generally not associated with an increased risk of renal calculi. In fact, regular physical activity can have health benefits.
B. Eats a vegetarian diet with cheese 2 to 3 times a day:
A vegetarian diet alone is not necessarily a risk factor for renal calculi. However, the inclusion of high-oxalate foods, such as certain types of cheese, may contribute to the formation of kidney stones.
C. Experiences additional stress since adopting a child:
Stress is not a direct risk factor for renal calculi. However, certain dietary and lifestyle factors play a more significant role in stone formation.
D. Drinks several bottles of carbonated water daily:
This is the correct answer. Consuming large amounts of carbonated water, especially if it is high in phosphoric acid, can contribute to the formation of kidney stones. Carbonated beverages may increase the excretion of calcium in the urine, potentially leading to stone formation.
Correct Answer is B
Explanation
A. Evaluate the urine for a strong odor.
While evaluating urine for a strong odor can provide some information about a possible urinary tract infection (UTI), it is not the most immediate concern. The priority in this case is to assess for signs of systemic infection, and checking for a strong odor can be done later.
B. Measure her temperature and pulse rate.
This is the correct choice. Measuring temperature and pulse rate is a critical initial step to assess for signs of systemic infection. Fever and an elevated pulse rate can indicate that the infection may have spread beyond the bladder, possibly involving the kidneys.
C. Test her urine for the presence of hematuria.
Testing for hematuria (blood in the urine) is an important diagnostic step for a UTI, but it is not the first priority. Vital sign assessment takes precedence to determine the severity of the condition and the need for urgent intervention.
D. Palpate the right flank for tenderness.
Palpating the right flank for tenderness is a relevant physical assessment to check for kidney involvement, which is important in cases of suspected pyelonephritis. However, assessing vital signs is a more immediate and critical step to determine the severity of the condition.
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