60. A nurse on a medical surgical unit is receiving a client who is postoperative following a laparotomy. In which order should the nurse perform the following actions? (Move the steps, placing them in the order of performance. Use all the steps.)

Determine the client's airway patency

Evaluate the client's level of consciousness.

Auscultate the client's lung sounds.

Ask the client to rate their pain.

Answer and Explanation

The Correct Answer is A,C,B,D

A. Determine the client's airway patency: Ensuring the airway is patent is the highest priority in the immediate postoperative period because airway compromise can be life-threatening. This assessment is performed first to address the most critical physiological need.

B. Evaluate the client's level of consciousness: After airway and basic respiratory assessment, the nurse evaluates the client’s level of consciousness to detect neurological changes, sedation effects from anesthesia, or potential complications.

C. Auscultate the client's lung sounds: Respiratory assessment, including auscultation, identifies complications such as atelectasis or pneumonia. While vital, it follows confirming airway patency to prioritize immediate safety.

D. Ask the client to rate their pain: Pain assessment is important for comfort and recovery but is performed after addressing airway, breathing, and neurological status. It is lower priority compared with immediate physiological needs.

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Correct Answer is A

Explanation

A. Turn off the heparin drip: The client’s aPTT is significantly elevated and is accompanied by active bleeding, indicated by hematuria. Stopping the heparin infusion is the most immediate action because it removes the source of ongoing anticoagulation and helps prevent further bleeding. This stabilizes the situation before additional corrective measures are taken.

B. Administer protamine sulfate: Protamine sulfate is the reversal agent for heparin and may be required, but it should be given after the heparin infusion is stopped. Administering it without stopping the drip allows continued anticoagulation, reducing the effectiveness of the reversal. The reversal medication is a secondary intervention.

C. Repeat the aPTT now and in 1 hr: Rechecking coagulation labs is appropriate to monitor progress, but it does not address the immediate risk of ongoing bleeding. Delaying action while repeating labs can allow further anticoagulation and worsening hemorrhagic symptoms. Lab monitoring becomes relevant only after the heparin drip is stopped.

D. Obtain a portable chest x-ray: A chest x-ray would not address the current problem of excessive anticoagulation and active bleeding. There is no indication of a thoracic complication requiring imaging at this moment, and performing this step would delay urgent action. The priority is to stop the heparin and control bleeding.

A. Varenicline B. Disulfiram C. Sertraline D. Clonidine

Correct Answer is C

Explanation

A. Varenicline: Varenicline is used to aid smoking cessation by reducing cravings and withdrawal symptoms. It does not have efficacy in treating gambling disorder and is not indicated for behavioral addictions.

B. Disulfiram: Disulfiram is prescribed for alcohol use disorder to discourage alcohol consumption by causing unpleasant reactions when alcohol is ingested. It does not address the underlying behavioral or psychological aspects of gambling disorder.

C. Sertraline: Sertraline, a selective serotonin reuptake inhibitor (SSRI), can help reduce compulsive behaviors, impulsivity, and anxiety associated with gambling disorder. It may be used as part of a comprehensive treatment plan alongside therapy and behavioral interventions.

D. Clonidine: Clonidine is primarily used to treat hypertension, ADHD, and certain withdrawal symptoms. It does not target the compulsive behaviors or psychological aspects of gambling disorder and is not indicated for this purpose.

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60. A nurse on a medical surgical unit is receiving a client who is postoperative following a laparotomy. In which order should the nurse perform the following actions? (Move the steps, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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