A nurse is preparing a client for surgery and has just administered the preoperative injection.
Which of the following actions should the nurse take?
Take the client to the bathroom to void.
Ask the client to verify the surgical site.
Review deep breathing and coughing exercises.
Raise the side rails on the bed.
The Correct Answer is D
A. Taking the client to the bathroom after administering a preoperative sedative increases the risk of falls.
B. Surgical site verification should be completed before administering the preoperative medication.
C. Teaching should be done before giving the medication, as the sedative may impair learning and recall.
D. Raising the side rails helps ensure client safety by preventing falls after the medication has been administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
Correct Answer is B
Explanation
A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.
B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.
C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.
D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.
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