Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client. There are six tabs that contain separate categories of data.)
Provide the client with ice chips
Discontinue nasogastric tube
Reinforce preoperative teaching
Start the prescribed antibiotics
The Correct Answer is C
A. Provide the client with ice chips: The client is on NPO status in preparation for surgery. Offering ice chips could increase the risk of aspiration or delay surgical procedures, so this action is not appropriate at this time.
B. Discontinue nasogastric tube: The NG tube is necessary to decompress the stomach and relieve nausea from the small-bowel obstruction. Removing it before surgery or resolution of obstruction could worsen vomiting and distention, so discontinuation is not indicated.
C. Reinforce preoperative teaching: Preoperative teaching helps reduce anxiety, improve cooperation, and prepare the client for what to expect during and after the exploratory laparotomy. This action is appropriate and supports client safety and understanding.
D. Start the prescribed antibiotic: The prescription for Cefazolin is 2 g IV and is ordered "on call for surgery." This means the antibiotic should be administered just before the surgical procedure begins, to ensure therapeutic levels are present in the bloodstream when the incision is made.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
• Dyspnea: Dyspnea is a hallmark sign of fat embolism syndrome, which can occur after long bone fractures such as a tibial fracture. Fat globules enter circulation, causing respiratory distress, hypoxia, and altered mental status.
• Increased pain at incision site: Severe, unrelieved pain is an early indicator of acute compartment syndrome due to increased pressure within the fascia. Pain can also indicate infection if accompanied by local inflammatory changes.
• Tingling sensation to right foot: Paresthesia, such as tingling or numbness, reflects nerve compression from elevated compartment pressure and is an early neurovascular sign of acute compartment syndrome.
• Swelling at incision site: Swelling that is taut or tense is a key indicator of acute compartment syndrome. Swelling can also signal local infection due to inflammation, erythema, or fluid accumulation around the incision.
Correct Answer is B
Explanation
- Location A points to the eye area which is where conjunctival pallor (paleness) might be observed in anemia, but not cheilosis.
- Cheilosis, or angular cheilitis, is a common clinical manifestation associated with iron-deficiency anemia, as well as deficiencies in B vitamins like riboflavin, pyridoxine and niacin. Location B points to the corners of the mouth (oral commissures). Cheilosis is characterized by the presence of fissures, scaling, and inflammation at these corners, where the lips meet.
- Location C points to the nose which is unrelated to cheilosis.
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