The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.
Which prescription should the nurse implement first?
Cefazolin 1 gram intravenously every 6 hours.
Complete blood cell count (CBC) in the morning.
Straight catheterization if unable to void.
Advance from clear liquids as tolerated.
The Correct Answer is A
The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.
This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
Choice A rationale
The patient is resting and cooperative, which indicates a calm and alert state, not agitation. Orientation x means the patient is aware of person, place, time, and situation, which is a normal finding. Dizziness is not mentioned in the patient’s condition. Pupils being equal and reactive to light is a normal finding and does not indicate a neurological issue.
Choice B rationale
Bradycardia refers to a slower than normal heart rate, which is not mentioned in the patient’s condition. Weak bilateral radial pulses could indicate poor blood circulation, but this is not mentioned in the patient’s condition. Capillary refill of 2 seconds is a normal finding. The absence of lower leg edema is a normal finding and does not indicate a cardiovascular issue.
Choice C rationale
Clear breath sounds are a normal finding and indicate that the patient’s lungs are free of obstructions or fluid.
Choice D rationale
The last reported bowel movement being 4 days ago could indicate constipation, but this is not mentioned in the patient’s condition.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.
The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.
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