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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Administering oxygen is important, but the priority is reversing the opioid-induced respiratory depression with naloxone. Oxygen alone will not address the underlying cause of the decreased level of consciousness.
B. Administering naloxone (Narcan) is the priority intervention because it is an opioid antagonist that will reverse the effects of morphine and other opioids, improving respiratory function and consciousness.
C. Opening the airway is important, but the primary issue here is opioid overdose, which requires naloxone administration for reversal of respiratory depression.
D. Placing the patient in the shock position is not indicated in this scenario. The focus should be on reversing opioid toxicity, not on positioning for shock.

A. Withhold medication for phantom limb pain as it isn't real pain. B. Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible. C. Continue using the limb prosthesis even if skin appears irritated. D. Have the client lay prone for 30 minutes, 3-4 times a day.

Correct Answer is D

Explanation

A. Withholding medication for phantom limb pain is inappropriate. Phantom limb pain is a real phenomenon, and it should be managed with appropriate analgesics or other pain management strategies.
B. Keeping the residual limb elevated immediately after surgery is not recommended for prolonged periods as it can lead to contractures. The goal is to avoid excessive flexion at the hip and promote proper positioning.
C. Continuing to use the limb prosthesis when skin is irritated could worsen the irritation and cause skin breakdown. Proper skin care and regular monitoring are essential before using the prosthesis.
D. Laying prone for 30 minutes, 3-4 times a day is an appropriate intervention to prevent hip contractures and encourage proper alignment of the residual limb. This helps to maintain the flexibility of the hip joint and prepares the client for prosthetic fitting.

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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?

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