The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?
Complete blood cell count (CBC) in AM.
Straight catheterization if unable to void.
Advance from clear liquids as tolerated.
Cefazolin 1 gram intravenously every 6 hours.
The Correct Answer is B
A. A complete blood cell count (CBC) is important for monitoring but is not an immediate priority during the admission process.
B. Straight catheterization if unable to void is a priority intervention to prevent bladder distention and complications following surgery.
C. Advancing from clear liquids as tolerated can be important for nutrition but does not address immediate postoperative concerns regarding urinary function.
D. Administering Cefazolin is important for preventing infection but should be prioritized after ensuring the client can void or addressing any issues with urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Client is awake and following commands: Unrelated: This finding indicates the client's level of consciousness and responsiveness, which is not directly related to the effects of furosemide. While improving fluid status can contribute to overall well-being, this finding can be influenced by various factors unrelated to the medication.
Blood pressure 122/85 mm Hg: Therapeutic: The decrease in blood pressure indicates a positive therapeutic effect of furosemide, which is a diuretic used to reduce fluid overload and lower blood pressure in patients with heart failure. The improvement from 142/99 mm Hg to 122/85 mm Hg suggests successful fluid management.
Prothrombin time/international normalized ratio: Unrelated: This laboratory finding does not directly correlate with the administration of furosemide. It is more relevant to the patient’s anticoagulation therapy (warfarin) and is monitored separately from diuretic therapy.
Potassium 3.1 mEq/L: Non-therapeutic: This finding represents a non-therapeutic side effect of furosemide. Furosemide can cause hypokalemia (low potassium levels) due to increased urinary potassium excretion. A potassium level of 3.1 mEq/L is concerning and requires monitoring and possible potassium supplementation.
Clear breath sounds: Therapeutic: The presence of clear breath sounds indicates improved lung function and resolution of pulmonary congestion, which is a therapeutic outcome of effective diuretic therapy like furosemide. The reduction in edema and fluid overload can lead to better oxygenation and breathing efficiency.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
This client is at risk for VTE due to several factors, including being postpartum, prolonged labor (25 hours), and potential immobility after delivery. Additionally, the presence of a 4th-degree laceration may lead to decreased mobility, increasing the risk of blood clots.
Wound Dehiscence:
The client has a 4th-degree laceration, which involves a significant degree of tissue damage and may require careful monitoring for proper healing. Factors such as infection (noted by slight fever), tension on the wound, or inadequate healing can contribute to the risk of dehiscence.-
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