The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Cefazolin 1 gram IV every 6 hours.

Complete blood cell count (CBC) in AM.

Advance from clear liquids as tolerated.

Straight catheterization if unable to void.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

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Correct Answer is C

Explanation

Choice A reason: Confirming the continuous passive motion device is intact is important but secondary to assessing the source of the drainage.

Choice B reason: Withholding the next dose of low molecular weight heparin should only be done based on a healthcare provider's order after assessing the situation.

Choice C reason: Determining if the wound drainage device is functioning correctly is essential to manage the excessive drainage and ensure that there is no blockage or malfunction.

Choice D reason: Monitoring the client's WBC count is important for detecting infection but is not the immediate action required for managing active drainage.

A. Measure the client's vital signs before the client walks. B. Determine if the client needs to have a gait belt applied. C. Report the onset of any dizziness or lightheadedness. D. Instruct the client about signs of orthostatic hypotension. E. Offer to assist the client to void prior to walking in the hall.

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

Explanation

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

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The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

Correct Answer is C

Explanation

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

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

Explanation

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