The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

Have the client sign the surgical and transfusion permits.

Notify the healthcare provider of the client's medication history.

Ensure that the potential for bleeding is explained to the client.

Observe the heparin injections sites for signs of bruising.

Answer and Explanation

The Correct Answer is B

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.

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Correct Answer is ["125"]

Explanation

To calculate the infusion rate in mL/hr, you would convert the total volume of lactated Ringer's IV from liters to milliliters (since there are 1,000 milliliters in a liter, 3 liters is equivalent to 3,000 milliliters) and then divide by the total number of hours over which the infusion is to be administered. In this case, 3,000 mL divided by 24 hours results in an infusion rate of 125 mL/hr.

A. Acute pain related to renal calculus. B. Nutritional deficit related to nausea. C. Impaired renal function related to pain. D. Risk for aspiration related to vomiting.

Correct Answer is D

Explanation

A. Acute pain related to renal calculus is important and needs to be addressed, but managing potential life-threatening conditions, like aspiration, takes precedence.

B. Nutritional deficit related to nausea is also a concern but is not as urgent as preventing aspiration.

C. Impaired renal function related to pain could be important in the long term, but it does not pose an immediate risk like aspiration does. Therefore, it is not the highest priority.

D. Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus. Ensuring the airway is protected and that aspiration does not occur is critical.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)

Correct Answer is ["125"]

Explanation

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Correct Answer is D

Explanation

The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?

The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Patient Data. Exhibits Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize dropdown as the priority problem for this client, as evidenced by the client's statement, dropdown.

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently bum and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?