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 injection sites for signs of bruising.
The Correct Answer is B
A. While having the client sign permits is important, it is not the priority action in this situation.
B. Notifying the healthcare provider about the client's current heparin therapy is critical, as it may influence the timing of surgery and the risk of excessive bleeding during and after the procedure.
C. While explaining the potential for bleeding is important, it should occur after ensuring the surgical team is aware of the heparin use.
D. Observing injection sites for bruising is relevant but does not address the immediate concern regarding heparin use and potential bleeding during surgery.
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Correct Answer is B
Explanation
A. "Don't worry, I'm sure your son will visit."
This response is dismissive and assumes that the son will visit, which may not be the case. It may come across as insensitive.
B. "Your son hasn't been around much lately?"
This response reflects the patient's statement, encouraging them to elaborate. It shows empathy and gives the patient space to express their feelings.
C. "My son doesn't come to visit me either."
This response shifts focus away from the patient and may make them feel that their concern is trivialized.
D. "How terrible that he doesn't visit you."
This response is judgmental and might make the patient feel worse or lead them to think the nurse disapproves of their son.
Correct Answer is C
Explanation
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.