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. Complete ongoing focused assessments of a client with wrist restraints. B. Supervise a newly hired graduate nurse during an admission assessment. C. Transport a client who is receiving IV fluids to the radiology department. D. Administer PRN oral analgesics to a client with a history of chronic pain.

Correct Answer is A

Explanation

Choice A reason: Completing ongoing focused assessments, particularly for a client with wrist restraints, requires the clinical judgment and skills of an RN.

Choice B reason: Supervising a newly hired graduate nurse is important but can also be done by the charge nurse or another experienced RN.

Choice C reason: Transporting a client to the radiology department can be done by a UAP or PN.

Choice D reason: Administering PRN oral analgesics can be delegated to a PN.

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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

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