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?
Insert an indwelling urinary catheter.
Insert an NG tube.
Obtain consent for surgery.
Apply antiembolic stockings.
The Correct Answer is B
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
Correct Answer is A
Explanation
Let’s break down the problem step by step:
Step 1: Convert the client’s weight from pounds (lb) to kilograms (kg). We know that 1 kg = 2.2 lbs. So, we have: 220 lb ÷ 2.2 = 100 kg
Step 2: Calculate the total amount of naloxone needed. The doctor ordered 10 mcg/kg, and the client weighs 100 kg. So, we have: 10 mcg/kg × 100 kg = 1000 mcg
Step 3: Convert micrograms (mcg) to milligrams (mg). We know that 1 mg = 1000 mcg. So, we have: 1000 mcg ÷ 1000 = 1 mg
Step 4: Calculate the volume of naloxone solution needed. The available naloxone solution is 0.4 mg/mL. So, we have: 1 mg ÷ 0.4 = 2.5 mL
So, the nurse should administer 2.5 mL of naloxone. Since we are asked to round off to the nearest tenth, the final answer remains 2.5 mL.
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