On Day 2 at 16:00, the client is kept NPO.
An exploratory laparotomy is scheduled for tomorrow at 06:00. Metoclopramide 10 mg IV every 6 hours and Cefazolin 2g IV on call for surgery are ordered.
Which of the following actions should the nurse assist with?
Discontinue the nasogastric tube.
Provide the client with ice chips.
Start the prescribed antibiotic.
Reinforce preoperative teaching.
The Correct Answer is C
Choice A rationale
Discontinuing the nasogastric tube is not the best action to take at this time. The nasogastric tube may be necessary for decompression of the stomach or administration of medications and should not be removed without a specific order from the healthcare provider.
Choice B rationale
Providing the client with ice chips is not the most appropriate action. The client is kept NPO (nothing by mouth) before surgery to prevent aspiration during anesthesia. Therefore, giving the client ice chips could increase the risk of aspiration.
Choice C rationale
Starting the prescribed antibiotic is the correct action. Cefazolin is an antibiotic that is often given before surgery to prevent postoperative infections. Administering this medication as ordered can help to ensure that the client is adequately prepared for surgery.
Choice D rationale
While reinforcing preoperative teaching is an important part of nursing care, it is not the most immediate action that should be taken in this situation. The client’s physical preparation for surgery, including the administration of prescribed medications, should be prioritized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Marking the edges of steps can help a visually impaired person navigate their home more safely. This can be done with contrasting colors or textures to make the steps more visible.
Choice B rationale
Using low-wattage light bulbs is not recommended for visually impaired individuals. Instead, they may benefit from brighter lighting to enhance visibility.
Choice C rationale
Placing throw rugs over electrical cords is not safe as it can create a tripping hazard. It’s better to secure cords out of walkways.
Choice D rationale
Leaving doors slightly ajar can be dangerous for visually impaired individuals as they may walk into them. It’s safer to keep doors fully open or fully closed.
Correct Answer is D
Explanation
Choice A rationale
Experiencing incontinence whenever taking a diuretic may suggest a type of functional incontinence, where the incontinence is linked to the inability to reach a restroom due to the sudden urge to urinate caused by the diuretic23.
Choice B rationale
Leaking urine when sneezing is typically a symptom of stress incontinence, which occurs when pressure is placed on the bladder during physical movement or activity23.
Choice C rationale
A bladder that seems to empty without warning may suggest urge incontinence, which is characterized by a sudden, intense urge to urinate followed by an involuntary loss of urine23.
Choice D rationale
Frequently experiencing dribbling of urine is a common symptom of overflow incontinence, which occurs when the bladder doesn’t empty properly, leading to frequent or constant dribbling23.
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