A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?
Ensure that there is an incentive spirometer ready for when the patient gets to the PACU to help prevent atelectasis.
Provide preoperative teaching about preventing blood clots after surgery.
Report to the provider that the patient has allergies to sardines.
Administer the ordered preoperative intravenous antibiotic.
The Correct Answer is D
A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.
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Related Questions
Correct Answer is B
Explanation
A. While having the son verify understanding may seem appropriate, using a family member as a translator is not acceptable for informed consent due to the potential for miscommunication or bias.
B. Contacting the hospital translator ensures accurate and professional communication. A certified translator is required for legal and ethical reasons to ensure the patient fully understands the procedure, risks, and benefits.
C. Using the son to clarify questions may lead to inaccuracies or incomplete understanding. Professional translation services must be utilized in medical settings.
D. The son does not need to sign the consent form. The provider must ensure the patient understands the procedure, and the consent form is signed by the patient or their legal representative after professional translation.
Correct Answer is A
Explanation
A. Encouraging a low-sodium diet is inappropriate for a client with hyponatremia. Hyponatremia is a condition of low sodium levels in the blood, and the priority in managing this condition is to restore normal sodium levels, not to restrict sodium.
B. Padding the side rails of the bed is appropriate to protect the client from injury, especially if the client is at risk for seizures due to the electrolyte imbalance.
C. Providing a quiet and calm environment is beneficial for a client with hyponatremia, as it can help reduce the risk of seizures or agitation associated with the condition.
D. Having the client use the call light when toileting is needed is a standard precaution to ensure the client’s safety, especially if they are at risk of falls or confusion due to the electrolyte imbalance.
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