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 D
Explanation
Pelvic rocking exercises can help relieve lower back pain during pregnancy. The client can perform this exercise by getting on their hands and knees, keeping their back straight, and gently rocking their pelvis back and forth. This helps to stretch and strengthen the muscles in the lower back and pelvis.
A. Sit in a hot tub for 30 min every evening: Hot tubs and hot baths are not recommended during pregnancy as they can raise the body temperature too high, which can be harmful to the developing fetus.
B. Raise chairs to keep knees lower than hips: This recommendation is more appropriate for promoting good posture and reducing strain on the back, but it may not specifically address lower back pain.
C. Use the arms to pick up heavy items: It is important to avoid heavy lifting during pregnancy as it can strain the back and increase the risk of injury. It is recommended to use proper lifting techniques, such as bending the knees and using the leg muscles rather than the back muscles, to lift objects.
Correct Answer is B
Explanation
Isolate children who have varicella until the vesicles have formed crusts.
Isolating children who have varicella, also known as chickenpox, until the vesicles (blisters) have formed crusts is an important infection control measure. Varicella is highly contagious, and the fluid-filled vesicles can easily spread the virus to others. Keeping the child isolated until the vesicles have crusted over helps prevent the spread of the disease.
Children who have erythema infectious, commonly known as fifth disease in (option A) is incorrect because they, do not require short-term antibiotic therapy. Fifth disease is a viral infection caused by parvovirus B19 and is usually a self-limiting condition that resolves on its own without specific treatment.
Administration of childhood immunizations, such as the MMR (measles, mumps, rubella) vaccine in (option C) is incorrect because it, does not prevent exanthem subitem, also known as roseola infantum. Roseola infantum is usually a mild viral illness that primarily affects infants and young children. It is caused by human herpesvirus 6 (HHV-6) or human herpesvirus 7 (HHV-7) and is characterized by high fever followed by a rash.
Restricting fluids for children who have pertussis (whooping cough) in (option D) is not appropriate. In fact, it is important to encourage adequate fluid intake to prevent dehydration, especially in children who may have difficulty eating or drinking due to persistent coughing spells. Pertussis is a bacterial infection, and treatment typically involves antibiotics and supportive care.
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