The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?

Correct Answer: A

Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.

Correct Answer: C

Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.

Correct Answer: B

Rationale: To calculate the infusion rate for vancomycin, you need to divide the total volume by the total time of infusion. In this case, the total volume is 100 mL, and the total time is 1.5 hours. Therefore, 100 mL · 1.5 hours = 67 mL/hour. This means the nurse should program the infusion pump to deliver vancomycin at a rate of 67 mL/hour. Choice A (50) is incorrect as it does not reflect the correct calculation. Choice C (57) is incorrect as it is not the accurate calculation based on the provided information. Choice D (70) is incorrect as it does not correspond to the correct infusion rate calculation.

Correct Answer: D

Rationale: The correct answer is 'Wear long sleeves and pants.' This instruction is crucial in reducing the risk of Lyme disease because it helps minimize exposure to ticks that carry the disease. Ticks are commonly found in grassy and wooded areas, so covering up with long sleeves and pants can act as a physical barrier and prevent ticks from attaching to the skin. Choices A, B, and C are not directly related to preventing Lyme disease. Washing hands frequently is important for general hygiene but not specifically for preventing tick bites. Avoiding drinking lake water is more about preventing waterborne illnesses rather than Lyme disease. Not sharing personal products is important for preventing the spread of infections but is not directly related to Lyme disease prevention.

Correct Answer: C

Rationale: The correct first action for the nurse when a client expresses anxiety about a procedure is to encourage the client to discuss their fears. By allowing the client to express their concerns, the nurse can provide personalized support, address specific worries, and offer tailored information. This approach helps to establish trust, reduce anxiety, and promote a therapeutic nurse-client relationship. Offering information about the procedure steps (Choice A) may be helpful but should come after addressing the client's fears. Administering an anxiolytic (Choice B) should not be the first action as it focuses on symptom management rather than addressing the underlying cause of anxiety. Reassuring the client that the procedure is common and safe (Choice D) is important but should follow active listening and addressing the client's fears.