The nurse is preparing a client for surgery who was admitted to the emergency center 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 subcutaneously daily. What is the priority nursing action?

Have the client sign the surgical and transfusion permits.

Ensure that the potential for bleeding is explained to the client

Observe the heparin injections sites for signs of bruising.

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

Answer and Explanation

The Correct Answer is D

A. Have the client sign the surgical and transfusion permits:
While obtaining signed consent is important, the immediate concern is addressing the client's medication history, especially the use of heparin, which can contribute to bleeding.

B. Ensure that the potential for bleeding is explained to the client:
Education about the potential for bleeding is important, but the immediate action is to communicate the client's medication history to the healthcare provider for appropriate guidance.

C. Observe the heparin injection sites for signs of bruising:
Monitoring for bruising at injection sites is a consideration, but it is not the priority when the client is actively bleeding from an open fracture.

D. Notify the healthcare provider of the client's medication history:
This is the correct answer. Heparin is an anticoagulant, and its use can increase the risk of bleeding during surgery. The healthcare provider needs to be informed of the client's current medication history to make decisions regarding the timing and management of heparin therapy in the perioperative period.

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Correct Answer is D

Explanation

A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.

B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.

C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.

D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.

A. Irrigating the catheter manually. B. Monitoring catheter drainage. C. Discontinuing infusing solution. D. Decreasing the flow rate.

Correct Answer is B

Explanation

A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.

B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.

C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.

D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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