Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
.

Surgical consent form is not signed.

Client's pulse oximeter reading is 96%.

Preoperative chest x-ray report is not available.

Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).

Answer and Explanation

The Correct Answer is D

A.   The surgical consent form is crucial for ensuring that the client is informed about the procedure and agrees to it. While it's critical for legal and ethical reasons, this issue can often be resolved relatively quickly by having the client sign the form or addressing it with the surgeon.
B.   A pulse oximeter reading of 96% indicates that the client's oxygen saturation is within a generally acceptable range (normal is usually 95% to 100%). This reading suggests that the client's oxygen levels are adequate and typically would not require immediate action.
C.   The absence of a preoperative chest x-ray report can be significant, especially if the client has underlying respiratory or cardiac conditions. However, the immediate need for action depends on the urgency and the reason the x-ray was ordered.
D.   A serum potassium level of 2.8 mEq/L is critically low. The normal reference range is 3.5 to 5 mEq/L. Hypokalemia (low potassium) can lead to severe complications, including cardiac arrhythmias and muscle weakness, which can significantly impact the client's ability to safely undergo surgery. This condition requires immediate attention to correct the electrolyte imbalance before proceeding with the surgical procedure.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is the safest and most accurate option. Insulin dosing is critical, and an overdose can lead to hypoglycemia, a serious condition. By discarding the incorrect dose and starting anew, the nurse ensures the client receives the precise amount of insulin prescribed.
B. This option is inefficient and increases the risk of error. It involves using two different methods for insulin administration, which can lead to confusion and potential mistakes. Additionally, it doesn't address the initial error of dialing the incorrect dose.
C. This option is extremely dangerous. Administering more insulin than prescribed can lead to severe hypoglycemia. Wasting the remaining four units does not rectify the primary issue of the overdose.

D. Insulin pens are designed for precision. Altering the dialed dose after an error can compromise the accuracy of the insulin delivery system. This method is not reliable and can lead to inaccurate dosing.

A. Initiate a referral for ophthalmic evaluation as soon as possible. B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve C. Instruct the client to rest, and report to the emergency department if eye pain develops. D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

Nursing Test Bank

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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
.