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.

Answer and Explanation

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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Correct Answer is A

Explanation

Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.

A. Check the IV site for redness. B. Ensure the tubing connections are secure. C. Reposition the client's left arm. D. Flush the IV catheter.

Correct Answer is C

Explanation

This is because the most common cause of infusion pump alarms is occlusion or obstruction of the IV line, which can be due to kinking, bending, or compression of the tubing or catheter by the client's arm or body position. By repositioning the client's arm, the nurse can relieve the occlusion and restore the flow of the IV fluid.

This action should be done before checking for other possible causes of alarm, such as redness at the IV site (which could indicate infection or inflammation), loose tubing connections (which could cause leakage or air embolism), or clogged IV catheter (which could require flushing with saline or heparin solution).

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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?

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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?