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The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3.

The nurse is preparing the client for surgery. Which of the following actions should the nurse take. Select all that apply.

Assist with administration of AB positive blood products if needed.

Prepare client for insertion of 18-gauge peripheral IV prior to surgery.

Administer Rh, D immune globin prior to surgery.

Obtain a complete blood count.

Explain the surgical procedure to the client.

Remind client to be NPO prior to surgery.

Verify consent form is signed by the client.

Answer and Explanation

Correct Answer : B,C,D,F,G

Prepare client for insertion of 18-gauge peripheral IV prior to surgery: A large-bore IV catheter, such as an 18-gauge, is necessary before surgery to ensure rapid administration of fluids, medications, or blood products if needed during the procedure. It is a measure to support hemodynamic stability during anesthesia and surgery.
Administer Rh, D immune globin prior to surgery: The client's blood type is B negative. Because an ectopic pregnancy involves fetal tissue, and there's a potential for fetal-maternal blood mixing during the surgery, administering Rh(D) immune globulin (RhoGAM) is crucial to prevent Rh sensitization in Rh-negative women who may be carrying an Rh-positive fetus. This is typically given within 72 hours of a potential sensitizing event.
Obtain a complete blood count: A CBC is critical to assess hemoglobin, hematocrit, and platelet levels before surgery. This helps the healthcare team anticipate the risk of bleeding and determine if transfusions might be necessary during or after the laparoscopic procedure.
Explain the surgical procedure to the client: Explaining the surgical procedure is the provider's responsibility, not the nurse's role. The nurse can reinforce teaching and answer basic questions but should not be the primary person explaining the procedure or obtaining informed consent.
Remind client to be NPO prior to surgery: Maintaining NPO status is essential to reduce the risk of aspiration during anesthesia. The client should avoid eating or drinking for a specified time before surgery, following the facility's preoperative protocol.
Verify consent form is signed by the client: Verifying that the informed consent form is properly signed is a crucial nursing responsibility before surgery. It ensures legal compliance and confirms that the client has been informed about the procedure, risks, and alternatives.

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Correct Answer is ["A","C"]

Explanation

A. Review the need for the indwelling urinary catheter daily: Daily review of catheter necessity reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal when no longer needed limits bacterial entry and colonization, which significantly lowers infection rates in hospitalized clients.

B. Empty the drainage bag when it is half full: The drainage bag should be emptied when it is about two-thirds full, not half full, to prevent backflow and reduce strain on the system. Emptying too early or too often increases the risk of introducing pathogens into the closed system.

C. Use soap and water to provide perineal care: Using soap and water for perineal hygiene maintains cleanliness and reduces bacterial colonization near the catheter site. Routine perineal care is a critical intervention to minimize the risk of ascending infections into the urinary tract.

D. Place the drainage bag on the bed when transporting the client: The drainage bag must remain below bladder level during transport to prevent backflow of urine into the bladder. Placing the bag on the bed risks contamination and promotes reflux of potentially infected urine.

E. Encourage the client to drink 1000 mL of fluid daily: Although hydration generally helps prevent UTIs, this client is on a strict 1000 mL fluid restriction due to heart failure. Encouraging more fluid intake could worsen fluid overload and does not align with current prescribed therapy.

F. Change the indwelling urinary catheter tubing every 3 days: Routine changing of catheter tubing is not recommended unless clinically indicated (e.g., contamination, obstruction, infection). Unnecessary manipulation increases the risk of introducing pathogens into the urinary system.

A. WBC count 12,000/mm3 (5,000 to 10,000/mm3) B. Temperature 37.8° C (100° F) C. Respiratory rate 16/min D. Hgb 8 g/dL (less than 11 g/dL)

Correct Answer is D

Explanation

A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.

B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.

C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.

D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.

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The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. The nurse is preparing the client for surgery. Which of the following actions should the nurse take. Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in a medical-surgical unit. Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.

Correct Answer is ["A","C"]

Explanation

A nurse is caring for a client who is 24 hr postpartum. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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