Exhibits
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.
Check capillary refill on bilateral upper extremities.
Administer ondansetron 4 mg IV.
Inspect the bandage for drainage.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities. - Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV. - Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage. - Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. The practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients is best assigned to an adult who is one day postoperative for a laparoscopic cholecystectomy. This client’s care involves routine postoperative care and monitoring, which is within the PN’s scope of practice. The other clients have more complex needs that require the higher level of education and skills of an RN.
Correct Answer is A
Explanation
The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.
This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.
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