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

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) requires a negative airflow room and airborne precautions. This is to prevent the spread of tuberculosis (TB), an infectious disease that can be transmitted through airborne particles. The use of a particulate respirator mask by healthcare personnel is essential in protecting themselves from inhaling infectious aerosols. Implementing these precautions is critical in controlling the spread of TB within healthcare settings and ensuring patient and staff safety.

Choice B rationale

A client with genital herpes simplex II lesions does not require a negative airflow room or airborne precautions. Herpes simplex virus (HSV) is primarily transmitted through direct contact with infected lesions or body fluids. Standard precautions, including contact precautions when dealing with lesions, are adequate to prevent the spread of HSV. Negative airflow rooms and airborne precautions are not necessary for managing this condition.

Choice C rationale

Scarlet fever, complicated with pneumonia, primarily requires standard and droplet precautions rather than airborne precautions. Scarlet fever is caused by group A Streptococcus, which is spread through respiratory droplets. While pneumonia can increase the severity of the infection, negative airflow rooms and particulate respirators are not typically required. Droplet precautions, such as wearing masks and maintaining distance, are sufficient to prevent transmission.

Choice D rationale

Scabies is a parasitic infestation that spreads through direct skin-to-skin contact or contact with contaminated items such as bedding and clothing. Negative airflow rooms and airborne precautions are not necessary for managing scabies. Standard and contact precautions, including wearing gloves and gowns and thoroughly cleaning and disinfecting contaminated items, are adequate to prevent the spread of the mites causing scabies. The use of a particulate respirator mask is not required.

A. Participation of community leaders in planning the program. B. Morbidity data for breast cancer in women of all races. C. A listing of African-American women who live in the community. D. Technical assistance to produce a video on breast self-examination.

Correct Answer is A

Explanation

Choice A rationale

Participation of community leaders in planning the program is crucial because these leaders have an in-depth understanding of the community's needs and concerns. Their involvement ensures that the program is culturally relevant and addresses the specific health disparities faced by African-American women. Additionally, community leaders can help foster trust and encourage participation from community members, making the program more effective.

Choice B rationale

While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.

Choice C rationale

A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.

Choice D rationale

Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.

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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

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