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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Preoperative chest x-ray report is not available.

Surgical consent form is not signed.

Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).

Client's pulse oximeter reading is 96%.

Answer and Explanation

The Correct Answer is C

Choice A reason: While the chest x-ray report is important, it is not as immediately critical as a low potassium level.

Choice B reason: The surgical consent form is important but can be addressed quickly before surgery.

Choice C reason:

The correct answer is c) because a preoperative serum potassium level of 2.8 mEq/L is dangerously low and requires immediate correction to avoid cardiac complications during surgery.

Choice D reason: A pulse oximeter reading of 96% is within normal limits and does not require immediate action.

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Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

A. Visualize the abdominal incision. B. Notify the healthcare provider. C. Obtain sterile towels soaked in saline. D. Assure the client that such feelings occur with wound infections.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

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