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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Excessive thirst (polydipsia) is a common symptom of hyperglycemia due to dehydration caused by increased urination.
B. Anxiety and tremors are more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia.
C. Excessive urination (polyuria) is a hallmark of hyperglycemia as the body attempts to excrete excess glucose through urine.
D. "Acetone" or "fruity" breath odor is a characteristic sign of diabetic ketoacidosis (DKA), which can occur in severe hyperglycemia.
E. Slow, shallow respirations are not typically associated with hyperglycemia but may occur in cases of respiratory acidosis or DKA, where Kussmaul's breathing (deep, rapid breathing) is more common.
Correct Answer is A
Explanation
A. Hemoglobin A1C of 7.2 is diagnostic for diabetes. An A1C of 6.5% or higher is diagnostic for diabetes, as it reflects the average blood glucose levels over the past 2-3 months.
B. Fasting plasma glucose of 98 mg/dl is within the normal range (70-99 mg/dl). A fasting plasma glucose of 126 mg/dl or higher is diagnostic for diabetes.
C. Two-hour plasma glucose of 140 mg/dl is within the normal range (less than 140 mg/dl after a glucose tolerance test). A two-hour plasma glucose of 200 mg/dl or higher is diagnostic for diabetes.
D. Random plasma glucose of 110 mg/dl is within the normal range. A random plasma glucose of 200 mg/dl or higher, along with symptoms of hyperglycemia, would be diagnostic for diabetes.
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