A nurse is interviewing a preoperative patient scheduled for a total hip replacement. Which of the following failings would require the nurse to collaborate with the surgeon immediately before sending the patient to the operating room?

The client took warfarin 2.5 mg with a sip of water at 6 a.m.

The client took metoprolol 25 mg with a sip of water at 6 a.m.

The client took phenytoin 100 mg with a sip of water at 6 a.m.

The client took half their morning dose of insulin at 6 a.m.

Answer and Explanation

The Correct Answer is A

Choice A reason: Warfarin, an anticoagulant, increases bleeding risk during surgery. Taking it on the morning of a total hip replacement, a procedure with significant bleeding potential, is concerning. It inhibits vitamin K-dependent clotting factors, prolonging prothrombin time. Immediate surgeon collaboration is needed to assess bleeding risk and consider reversal agents like vitamin K or fresh frozen plasma.

Choice B reason: Metoprolol, a beta-blocker, is often continued perioperatively to maintain heart rate and blood pressure control, especially in patients with cardiovascular disease. Taking 25 mg with a sip of water is unlikely to pose a risk for a hip replacement. It helps prevent perioperative cardiac complications, so no immediate surgeon consultation is required.

Choice C reason: Phenytoin, an anticonvulsant, is typically continued before surgery to prevent seizures, especially in patients with epilepsy. A 100 mg dose with a sip of water is standard and does not increase surgical risks like bleeding or hemodynamic instability. It ensures therapeutic levels, so no urgent surgeon collaboration is necessary for this medication.

Choice D reason: Taking half the morning dose of insulin is generally safe for a diabetic patient undergoing surgery. It helps manage blood glucose levels without causing hypoglycemia during fasting. The surgical team can monitor and adjust glucose intraoperatively. This does not typically warrant immediate surgeon consultation unless severe hyperglycemia or hypoglycemia is present.

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Correct Answer is B

Explanation

Choice A reason: Checking blood glucose is important in stroke management to rule out hypoglycemia mimicking stroke symptoms, but it is not the first action. A neurological exam identifies stroke signs like weakness or speech deficits, guiding urgent interventions like thrombolytics. Glucose testing follows to ensure metabolic causes are addressed after confirming neurological deficits.

Choice B reason: Performing a neurological exam is the first priority in suspected stroke to identify focal deficits, such as hemiparesis, aphasia, or altered consciousness. This confirms the diagnosis and determines eligibility for time-sensitive treatments like thrombolytics or thrombectomy. Rapid assessment using tools like the NIH Stroke Scale ensures timely intervention to minimize brain damage.

Choice C reason: Obtaining a CT scan is critical to differentiate ischemic from hemorrhagic stroke but follows a neurological exam. The exam confirms stroke symptoms, ensuring the scan is warranted. CT scans guide treatment decisions but are not the first step, as clinical assessment drives the urgency and direction of diagnostic imaging.

Choice D reason: Monitoring blood pressure is important in stroke, as hypertension can worsen outcomes, but it is not the first action. A neurological exam identifies stroke symptoms, prioritizing rapid diagnosis and treatment. Blood pressure management follows to optimize cerebral perfusion, especially if thrombolytics are considered, but initial assessment takes precedence.

A. Flush catheter system daily B. Obtain a urine specimen for culture every 24 hours C. Secure the catheter to prevent movement D. Inspect urine for color, odor, and consistency E. Maintain a closed drainage system

Correct Answer is ["C","E"]

Explanation

Choice A reason: Flushing the catheter system daily is not recommended for CAUTI prevention. It disrupts the closed system, increasing the risk of introducing pathogens into the bladder. Maintaining a sterile, closed drainage system is critical to prevent bacterial entry, and flushing is only indicated for specific blockages, not routine care.

Choice B reason: Obtaining a urine specimen for culture every 24 hours is not a preventive measure for CAUTI. Routine culturing is unnecessary unless infection is suspected, as it increases manipulation of the catheter system, risking contamination. Cultures are diagnostic, not preventive, and frequent sampling may introduce bacteria, counteracting infection control efforts.

Choice C reason: Securing the catheter prevents movement, reducing trauma to the urethra and bladder mucosa. Movement can cause microtears, allowing bacterial entry and colonization, leading to CAUTI. Proper anchoring ensures the catheter remains stable, minimizing irritation and maintaining the integrity of the urinary tract’s natural barriers against infection.

Choice D reason: Inspecting urine for color, odor, and consistency monitors for signs of infection but does not prevent CAUTI. Changes like cloudiness or foul odor indicate an existing infection, not prevention. While useful for early detection, it is a reactive measure, not a proactive intervention to reduce the incidence of catheter-related infections.

Choice E reason: Maintaining a closed drainage system is critical for CAUTI prevention. A closed system minimizes bacterial entry into the catheter and bladder by preventing disconnection or external contamination. Breaks in the system, such as during bag changes, increase infection risk, making this a key intervention to reduce pathogen introduction.

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A nurse is interviewing a preoperative patient scheduled for a total hip replacement. Which of the following failings would require the nurse to collaborate with the surgeon immediately before sending the patient to the operating room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a suspected stroke. Which of the following assessments should the nurse perform first?

Correct Answer is B

Explanation

Which interventions should the nurse implement to prevent a catheter-associated urinary tract infection (CAUTI)? (Select all that apply)

Correct Answer is ["C","E"]

Explanation

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