A nurse in an emergency department is preparing a client for emergency surgery. The
client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?
Obtain consent for surgery.
Insert an indwelling urinary catheter.
Apply antiembolic stockings.
Insert an NG tube.
The Correct Answer is A
The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.
The other actions are important but not as urgent as obtaining consent.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.
Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.
Correct Answer is B
Explanation
A monthly calendar can help the client with Alzheimer's disease to orient to time and date and reduce confusion and anxiety. The nurse should encourage the family to use simple and clear reminders and cues to assist the client with daily activities and routines.
Covering electrical outlets with tape is not necessary and may pose a fire hazard. Keeping the client's bedroom dark at night may increase the risk of falls and injuries. A large-face clock may be helpful, but not as much as a calendar.
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