A 2-week-old patient born with a myelomeningocele is to undergo surgical repair of this defect. Which nursing action is of the highest priority in her preoperative care?
Monitoring for apical pulse every hour.
Maintaining the patient in a prone position.
Providing the patient sensory stimulation.
Keeping a strict record of the patient's intake and output.
The Correct Answer is A
Choice A rationale:
Monitoring the apical pulse is of the highest priority for a patient with a myelomeningocele preoperatively. A myelomeningocele is a neural tube defect that can lead to neurologic complications. Monitoring the apical pulse every hour helps detect any signs of cardiac distress or neurological compromise, allowing prompt intervention.
Choice B rationale:
Maintaining the patient in a prone position is not the priority in this situation. While positioning can be important, monitoring vital signs takes precedence over positioning.
Choice C rationale:
Providing sensory stimulation is important for the patient's overall well-being, but it's not the highest priority preoperatively. Monitoring vital signs and assessing for potential complications take precedence.
Choice D rationale:
Keeping a strict record of the patient's intake and output is important for general care, but it's not the highest priority in the immediate preoperative period. Monitoring vital signs and detecting signs of distress come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reviewing the patient's complete blood count.
Choice A rationale:
Measuring height is not a priority when administering zidovudine.
Choice B rationale:
Monitoring weight gain is important but not the first priority.
Choice C rationale:
Reviewing the complete blood count is crucial before administering zidovudine, as this medication can cause bone marrow suppression. Checking for changes in white blood cell counts, hemoglobin, and platelet levels is essential to ensure the patient can tolerate the medication without severe adverse effects.
Choice D rationale:
Reviewing the patient's chemistry profile is relevant, but assessing blood counts is more critical due to zidovudine's potential impact on bone marrow function.
Correct Answer is B
Explanation
Choice A rationale:
The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.
Choice B rationale:
IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.
Choice C rationale:
The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.
Choice D rationale:
Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.
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