The nurse is performing a presurgical admission assessment of the client. Which client statement needs the most immediate follow-up?
"I feel very hungry; I haven't eaten foods or had any fluids for the past 12 hours."
"I took all my meds including warfarin and atenolol with a sip of water this morning
"I donated my own blood in case I need a transfusion, the last donation was 4 days ago.”
"I brought a copy of my health care directive in case my heart stops during surgery.”
The Correct Answer is B
A. "I feel very hungry; I haven't eaten foods or had any fluids for the past 12 hours.": A 12-hour fast may be uncomfortable but is generally acceptable preoperatively (many patients are NPO from midnight); this does not usually require immediate intervention.
B. "I took all my meds including warfarin and atenolol with a sip of water this morning.": Immediate follow-up is needed because warfarin increases perioperative bleeding risk and is commonly held before surgery; the team needs to know right away to manage bleeding risk and possibly delay or alter the procedure.
C. "I donated my own blood in case I need a transfusion, the last donation was 4 days ago.": Incorrect (but important). Recent autologous donation may affect hemoglobin/eligibility for transfusion and should be checked, but it is less immediately dangerous than someone taking warfarin the morning of surgery.
D. "Brought a copy of my health care directive in case my heart stops during surgery.": Bringing an advance directive is appropriate and useful; it does not pose an immediate safety concern requiring urgent follow-up.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will not drink coffee, tea, or any type of cola.": Caffeine restrictions are not a standard teaching point for montelukast.
B. “It is alright to take this medication if I am trying to get pregnant.": While montelukast is commonly continued if needed, pregnancy-related advice should be individualized; this statement is not the classic teaching point tested.
C. "I will take this medication at the beginning of an asthma attack.": Montelukast is a maintenance (controller) medication and is not for acute relief of asthma attacks.
D. “I should not decrease the dose or suddenly stop taking this medication.": Montelukast is a daily maintenance leukotriene modifier for chronic control; patients should take it regularly as prescribed and not stop it abruptly as it is not a rescue medication.
Correct Answer is B
Explanation
A. "Drink a glass of water before taking your medications.": Drinking water before inhalation is not the primary preventive step for thrush.
B. "Rinse your mouth after using your inhaler medications.": Rinsing and spitting after inhaled corticosteroids (fluticasone) reduces residual steroid in the oropharynx and lowers the risk of oropharyngeal candidiasis.
C. "Wait at least one minute before taking the next medication.": Waiting between puffs of bronchodilator doses is appropriate, but this instruction doesn’t specifically prevent thrush from inhaled steroids.
D. "Close your mouth tightly around the inhaler.": Proper inhaler technique varies by device; while a good seal is important for some inhalers, it does not replace rinsing to prevent candidiasis.
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