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.
None
None
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 A
Explanation
A.
A. Justice refers to fairness and equity in the distribution of resources and the treatment of
individuals. By spending an equal amount of time with each client regardless of their background or actions, the nurse is demonstrating the principle of justice.
B. Autonomy refers to respecting the right of individuals to make their own decisions about their healthcare. While important, it does not directly relate to the nurse's equal allocation of time.
C. Nonmaleficence refers to the duty to do no harm. While relevant to nursing care, it does not directly apply to the equal distribution of time among clients.
D. Veracity refers to truthfulness and honesty in communication. While important, it does not directly relate to the allocation of time among clients.
Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
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