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 B

Explanation

Choice A rationale

Mixed berries are rich in antioxidants and nutrients, but they do not specifically provide the calcium and vitamin D necessary to support bone health in postmenopausal women, who are at increased risk for osteoporosis.

Choice B rationale

Low-fat yogurt is a good source of calcium and vitamin D, which are vital for maintaining bone density and preventing osteoporosis in postmenopausal women. These nutrients are crucial as estrogen levels drop, increasing the risk of bone loss.

Choice C rationale

Carrots are high in beta-carotene and fiber but do not significantly contribute to calcium and vitamin D intake. While beneficial for overall health, they are not the primary focus for bone health in postmenopausal women.

Choice D rationale

Beets offer various vitamins and minerals but lack substantial amounts of calcium and vitamin D. They are not emphasized for bone health in postmenopausal women, who need to prioritize nutrients that support bone density.

A. Measure and discard residual gastric contents before feeding. B. Use the syringe plunger to push formula at a rate of 5 mL per minute. C. Hold the infant with head and shoulders slightly elevated. D. Microwave refrigerated formula to room temperature.

Correct Answer is C

Explanation

Choice A rationale

Measuring and discarding residual gastric contents before feeding is generally avoided in infants because it can disrupt gastrointestinal function and increase the risk of aspiration. Instead, monitoring for signs of intolerance or high residuals through clinical observation is preferred.

Choice B rationale

Using the syringe plunger to push formula at a rate of 5 mL per minute is inappropriate because it can create excessive pressure, leading to discomfort, aspiration, or injury to the gastrointestinal tract. Gravity feeding or using an appropriate pump at a controlled rate is safer.

Choice C rationale

Holding the infant with head and shoulders slightly elevated during feeding is recommended. This position helps to prevent aspiration by ensuring that the formula flows smoothly through the esophagus and into the stomach, reducing the risk of regurgitation.

Choice D rationale

Microwaving refrigerated formula to room temperature is unsafe because microwaving can create hot spots in the formula, posing a burn risk to the infant. It is safer to warm the formula by placing the bottle in warm water and ensuring an even temperature.

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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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