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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. BMI 32: A BMI of 30 or higher indicates obesity, which is a major risk factor for developing type 2 diabetes mellitus. Excess body fat, especially abdominal fat, contributes to insulin resistance, increasing the likelihood of diabetes.
B. Alcohol use: While excessive alcohol intake can affect overall health, moderate alcohol consumption is not a primary direct risk factor for type 2 diabetes. Other factors like obesity and sedentary lifestyle have a stronger association.
C. Age 35 years: Advancing age increases diabetes risk, but significant age-related risk typically rises after age 45. At 35 years old, age alone is not considered a major risk factor without additional contributing conditions.
D. Medical history of asthma: Asthma is a chronic respiratory condition but is not recognized as a risk factor for type 2 diabetes mellitus. The primary risk factors involve metabolic, genetic, and lifestyle components rather than respiratory history.
Correct Answer is A
Explanation
A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.
B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.
C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.
D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.
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