Question

A client has been admitted to the Ambulatory Surgery Department and will be having an elective procedure chis morning. While completing the admission assessment, the nurse finds the following: . no known drug allergies • Take Advil twice daily • Allergic co pitted fruits • has had seven surgeries in the past 10 years is a technician in a dental office • develops a rash if wears antiembolism hose The nurse: 1. Removes all non-latex produces from the client's room 2. Uses powdered gloves when providing care co chis client 3. Informs the surgeon chat the client has type I hypersensitivity to latex 4. Asks the client further questions related co allergies and symptoms. During routine assessment of the client who is receiving continuous enteral nutrition via naso- intestinal tube, the nurse notes absent bowel sounds and will: 1. Increase the rate of the feeding to stimulate peristalsis 2. Stop the feedings and notify the physician immediately 3. Observe the client for potential diarrhea or constipation 4. Decrease the rate of the tube feeding until bowel sounds return The nurse completes documentation related to medication administration by: 1. Noting this on the MAR immediately after the client cakes the medication 2. Recording medication administration times and dosages ac the end of the shift 3. Erasing cach medication from the MAR as soon as the drugs have been administered 4. Giving a list of medications taken and requesting the UAP to write the times into the MAR The UAP reports that the hearing-impaired client is alert and oriented but isn't responding co verbal communication chis morning. The nurse will: 1. Instruct the UAP co check the condition of the batteries in the client's hearing aid 2. Remove the hearing aid and immerse it in sterile normal saline solution to clean it thoroughly 3. Withhold any medications chat might be interfering with verbal abilities until further notice 4. Notify the physician that the client's condition is deteriorating as compared which yesterday The nurse is caring for a client who had abdominal surgery under general anesthesia 12 hours ago and writes which of the following as an appropriate goal? 1. Client will not be able to walk unassisted for 3 days. 2. Have client turn, cough, and deep breathe whenever possible until tomorrow. 3. Client will have active bowel sounds in all four quadrants by 24 hours after surgery. 4. Nurse will have the diene perform foot and ankle exercises in bed three times chis shift. A client has returned from the PACU after abdominal surgery. The nurse notes the following: .97.3-80-20 132/78 . Urine output 35 ml in past hour Client drowsy but arousable • IV infusing at 125 ml/hr

Answer 1

1.3.inform the surgen that she has an allergy on latex material.so,that he can take precautions while doing surgery

2.2 .stop the feeding and inform the doctor immediately to prevent further comlications.

3.1.record in the medication chart soon after administering medication to prevent medication errors.

4.1.if the battery is dead it may stop functioning.so the staff should check it first.

5.3.bowel should prsent with in 24 hours of surgery is vital in post operative cases.