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The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has a fracture of the femur and is bleeding at the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin subcutaneously daily. Which is the priority nursing action?
- A. Notify the healthcare provider of the client's medication history.
- B. Ensure that the potential for bleeding is explained to the client.
- C. Have the client sign the surgical and transfusion permits.
- D. Observe the heparin injection sites for signs of bruising.
Correct Answer: A
Rationale: Notifying the healthcare provider of the client's heparin use is critical as it increases bleeding risk, requiring potential adjustments to the surgical plan or anticoagulation management.
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A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient's laboratory values should the nurse review?
- A. Blood pH level
- B. Hematocrit
- C. White blood cell (WBC) count
- D. Platelet count
Correct Answer: C
Rationale: WBC count indicates infection, relevant to purulent drainage in a burn wound.
A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?
- A. Cold and dry skin.
- B. Facial puffiness and periorbital edema.
- C. Hematocrit of 30% (0.30 volume fraction).
- D. Further decline in the level of consciousness.
Correct Answer: D
Rationale: A further decline in consciousness indicates worsening hypothyroidism or myxedema coma, requiring urgent intervention.
A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?
- A. Call the PACU nurse to prepare for prolonged ventilatory support.
- B. Hold a prescription for dantrolene until the fever is reduced.
- C. Prepare ice packs for placement in the patient's axillary area.
- D. Determine if prescribed antibiotics were administered preoperatively.
- E. None
- F. None
Correct Answer: C
Rationale: Applying ice packs addresses hyperthermia in malignant hyperthermia, a critical response to succinylcholine-induced symptoms.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Monitor skin for breakdown.
- B. Strict intravenous (IV) fluid replacement.
- C. Encourage regular turning.
- D. Assess wound drainage daily.
Correct Answer: B
Rationale: Strict IV fluid replacement is critical to manage hypovolemia and prevent sepsis in suspected anastomosis leakage.