A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Advance from clear liquids as tolerated.

Cefazolin 1 gram IV every 6 hours.

Straight catheterization if unable to void.

Complete blood cell count (CBC) in the morning.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.

Choice B rationale

Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.

Choice C rationale

Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.

Choice D rationale

Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.

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Correct Answer is A

Explanation

Choice A rationale

Withholding the dose is the safest action to avoid potential overdose or toxicity. Digoxin has a narrow therapeutic window, and administering an additional dose without knowing how much was absorbed could lead to dangerous side effects.

Choice B rationale

Administering a half dose now is not recommended because it is unclear how much of the original dose was absorbed. This could result in either an insufficient dose or an overdose, leading to ineffective treatment or potential toxicity.

Choice C rationale

Giving another dose is not safe because there is a risk of overdosing the infant. Digoxin toxicity can cause serious complications, and it is crucial to avoid administering more medication until the next scheduled dose.

Choice D rationale

Mixing the next dose with food is not appropriate because it does not address the immediate concern of potential overdose. The priority is to withhold the dose and monitor the infant's condition.

A. Develop a safety plan. B. Perform a thorough physical assessment. C. Report findings to Adult Protective Services. D. Confront the abuser about concerning actions. E. Take photographs to document the abuse or neglect. F. Complete a comprehensive history. G. Throw away soiled clothing. H. Query the client in front of the suspected abuser.

Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A rationale: Developing a safety plan is essential to ensure the client's immediate and long-term safety. This involves planning for safe living arrangements and other protective measures.

Choice B rationale: Performing a thorough physical assessment helps document the extent of injuries or neglect and provides critical information for further actions and interventions.

Choice C rationale: Reporting findings to Adult Protective Services is a necessary step to ensure that the client receives the appropriate protection and support from authorities.

Choice E rationale: Taking photographs to document the abuse or neglect provides visual evidence that can be used in investigations and legal actions to protect the client.

Choice F rationale: Completing a comprehensive history helps understand the full context of the client's situation, including past medical history, social support, and potential risk factors for mistreatment.

Choice D rationale: Confronting the abuser about concerning actions is not advisable as it can escalate the situation and put the client at greater risk.

Choice G rationale: Throwing away soiled clothing may destroy potential evidence and is not a priority intervention in the context of suspected elder mistreatment.

Choice H rationale: Querying the client in front of the suspected abuser can intimidate the client and prevent them from speaking freely about their situation.

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A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is A

Explanation

A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment. Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","C","E","F"]

Explanation

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