Exhibits Here
The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.
Obtain a complete blood count.
Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery.
Administer Rh, D immune globulin prior to surgery.
Explain the surgical procedure to the client.
Verify consent form is signed by the client.
Assist with the administration of AB-positive blood products if needed.
Remind the client to be NPO prior to surgery.
Correct Answer : A,B,C,E,G
Based on the given information, the nurse should take the following actions in preparation for surgery:
- Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
- Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
- Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to
Rh-positive blood.
- Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
- Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.
The following actions are not indicated based on the given information:
- Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
- Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Determine the acuity and number of casualties arriving at the facility
During a mass casualty event, the nurse working on a medical-surgical unit can anticipate being assigned the task of determining the acuity and number of casualties arriving at the healthcare facility. This involves assessing the severity of injuries and prioritizing care based on the level of urgency. The nurse will be responsible for triaging and assigning appropriate resources to each patient based on their condition.
Provide informational updates to members of the media. In (option A) is incorrect. While communication and coordination with the media may be necessary during a mass casualty event, this is typically handled by designated spokespersons or hospital administration. Nurses are primarily focused on providing direct patient care and managing the influx of patients.
Assist in discharging stable clients to home in (option C) is incorrect. During a mass casualty event, the focus is on providing care to the injured and managing the influx of casualties. Discharging stable clients to home would not be a priority task during such an event.
Delegate tasks to emergency healthcare specialists in (option D) is incorrect. Nurses may collaborate with emergency healthcare specialists during a mass casualty event, but they usually take on leadership roles in coordinating and providing direct care. Nurses are responsible for assigning tasks and coordinating the efforts of the healthcare team, including specialists, to ensure effective care delivery.
Correct Answer is C
Explanation
Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect the skin. Proper skin care is important for individuals with SLE to minimize potential flare-ups or exacerbation of skin symptoms. The recommended approach to skin care in SLE includes gentle cleansing and moisturizing.
"I will use an astringent on my face." Astringents are typically not recommended for individuals with SLE as they can be harsh on the skin and may cause irritation or dryness.
"I will cleanse my skin using an antibacterial soap." While it is important to keep the skin clean, using an antibacterial soap is not specifically required for individuals with SLE. Gentle,
Non-irritating cleansers without antibacterial properties are generally recommended.
"I will limit my time in the tanning bed to 15 minutes." Exposure to ultraviolet (UV) radiation, such as from tanning beds, can be particularly harmful to individuals with SLE. UV radiation can trigger or worsen skin manifestations and may lead to disease flares. Therefore, it is generally advised for individuals with SLE to avoid tanning beds altogether.
In addition to gentle cleansing and moisturizing, individuals with SLE should also practice sun protection, including wearing sunscreen with a high sun protection factor (SPF) and using protective clothing and accessories (such as hats and sunglasses) when exposed to the sun. Regular check-ups with a healthcare provider and following their recommendations are important for managing SLE and its associated skin manifestations.
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