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 NG tube.

Apply antiembolic stockings

insert an indwelling armory catheter

Answer and Explanation

The Correct Answer is A

Choice A reason:

Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or

Choice B reason:

Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.

Choice C reason:

Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.

Choice D reason:

Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.

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Correct Answer is C

Explanation

Choice A Reason:

NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.

Choice B Reason:

Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.

Choice C Reason:

Chest physiotherapy vest should be recommended. Cystic fibrosis (CF) is a genetic disorder that affects the lungs and can result in the accumulation of thick, sticky mucus. Chest physiotherapy techniques, including the use of a chest physiotherapy vest, help mobilize and loosen mucus in the airways. The vest uses mechanical vibrations to assist with airway clearance, which is an important aspect of managing CF to prevent infections and improve lung function.

Choice D Reason:

Peak flow meter should not be recommended - Peak flow meters are used to monitor and manage conditions like asthma, which can also affect lung function but are not specific to cystic fibrosis management.

A. WBC count 8.400/mm3 B. Serosanguineous exudate noted on dressing change C. Reports pain of 4 on a scale from 0 to 10 when coughing D. Hemoglobin 10 mg/dL

Correct Answer is D

Explanation

Choice A reason:

WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.

Choice B reason:

Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.

Choice C reason:

Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.

Choice D reason:

Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.

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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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