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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Related Questions
Correct Answer is C
Explanation
A frozen fruit juice bar for dessert is a low-sodium option that can satisfy the client's sweet tooth. According to the National Health and Nutrition Examination Survey, Americans consume about 3700 mg of sodium daily, which is much higher than the recommended 2300 mg for the general population and 1500 mg for those with heart failure. Excessive sodium intake can lead to fluid retention, hypertension, and worsening of heart failure symptoms. Therefore, the client should avoid high-sodium foods such as vegetable juice, garlic and onion salts, and mayonnaise.
Correct Answer is D
Explanation
Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.
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