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 C
Explanation
A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.
Correct Answer is ["B","D","E"]
Explanation
A. Intact motor function is not a sign of compartment syndrome. Motor deficits, rather than intact function, would raise concern for this condition.
B. A capillary refill time of 5 seconds is prolonged and indicates impaired circulation, which is a sign of compartment syndrome.
C. A bounding pulse is not consistent with compartment syndrome. Pulses may initially remain normal but can diminish as the condition progresses.
D. Pallor to the lower extremity suggests compromised blood flow, which is a hallmark of compartment syndrome.
E. Numbness and tingling (paresthesia) indicate nerve compression, a common symptom of compartment syndrome.
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