What is the priority nursing action for this patient?

Correct Answer: D

Rationale: The correct answer is option D: Administer IV fluid support with supplemental thiamine as ordered. In this scenario, the patient is likely presenting with symptoms of alcohol withdrawal syndrome, which can lead to severe complications like delirium tremens. Administering IV fluid support helps to prevent dehydration and maintain electrolyte balance, while thiamine supplementation is crucial in preventing Wernicke's encephalopathy, a common complication of alcohol withdrawal. Option A: Obtaining an order for a blood alcohol level may be important for assessing the patient's alcohol intoxication status but is not the priority in managing acute alcohol withdrawal. Option B: Contacting the family for additional history is valuable for holistic care but does not address the immediate physiological needs of a patient experiencing alcohol withdrawal. Option C: Administering naloxone (Narcan) is used to reverse opioid overdose, not alcohol withdrawal symptoms. It is not indicated in this situation. Educationally, understanding the priority actions in managing alcohol withdrawal is essential for nurses caring for patients in acute care settings. Recognizing the signs and symptoms of withdrawal, and knowing the appropriate interventions, can help prevent severe complications and improve patient outcomes. Learning to prioritize interventions based on patient needs is a crucial skill in nursing practice.

Correct Answer: A

Rationale: In this scenario, the correct priority intervention for the patient is option A) Transportation arrangements to a safe house. This choice is the most critical because it addresses the immediate safety and well-being of the patient. By ensuring the patient is in a secure environment, we can prevent further harm or danger. Option B) Referral to a counselor is not the priority in this situation because the patient's safety is at risk, and addressing their mental health needs should come after ensuring their physical safety. Option C) Advise about contacting the police may be necessary at some point, but it is not the priority intervention. The immediate focus should be on removing the patient from the dangerous situation. Option D) Follow-up appointment for injuries is also not the priority as the patient's safety is in jeopardy. Once the patient is in a safe environment, then follow-up care for injuries can be arranged. In an educational context, it is important for healthcare providers to prioritize actions that ensure patient safety in situations of abuse or danger. Understanding the hierarchy of needs and immediate interventions can help students and professionals make informed decisions in critical situations to provide the best possible care for their patients.

Correct Answer: A

Rationale: In the context of a 65-year-old patient being transferred into the Post-Anesthesia Care Unit (PACU) from the Operating Room (OR), the initial assessment should prioritize addressing immediate life-threatening issues. Option A, focusing on airway, breathing, circulation, and wound site, is the correct choice. This approach aligns with the ABCs of emergency care - ensuring a patent airway, adequate breathing, and optimal circulation, while also assessing the surgical wound for any signs of bleeding, infection, or complications. Options B, C, and D are incorrect for several reasons. Option B, which mentions intake, output, and intravenous access, is more relevant to ongoing monitoring and management in the PACU rather than the immediate postoperative assessment. Option C, involving abdominal sounds, oxygen setting, and level of consciousness, is important but should come after the ABC assessment to ensure the patient's physiological stability. Option D, focusing on pulse oximeter, pupil responses, and deep tendon reflexes, is more indicative of a neurological assessment and would not address the immediate concerns of airway, breathing, and circulation. Educationally, understanding the prioritization of assessments in the PACU is crucial for nursing students and healthcare providers. Emphasizing the ABC approach ensures that critical issues are addressed promptly, potentially preventing adverse outcomes in postoperative patients. By explaining the rationale behind the correct choice and why the other options are less appropriate, learners can develop a solid foundation in perioperative care.

Correct Answer: A

Rationale: The correct answer is A) laboratory tests and perioperative medications. Performing surgery at an ambulatory day-surgery center offers the advantage of decreased need for extensive preoperative preparations such as laboratory tests and perioperative medications. This is because ambulatory centers are designed for same-day surgeries and aim to streamline the process, avoiding unnecessary tests and medications that may be required for inpatient procedures. Option B) preoperative and postoperative teaching by the nurse is incorrect because education and teaching by healthcare professionals are essential regardless of the surgical setting. Patients need to be well-informed about the procedure, postoperative care, and expectations for a successful recovery. Option C) psychologic support to alleviate fears of pain and discomfort is incorrect because emotional support is crucial for all patients undergoing surgery, whether in an ambulatory or inpatient setting. Addressing fears and providing psychological support are integral parts of holistic patient care. Option D) preoperative nursing assessment related to possible risks and complications is incorrect because thorough preoperative assessments are necessary in all surgical settings to ensure patient safety and identify any potential risks or complications that may arise during or after the procedure. In an educational context, understanding the advantages of different surgical settings like ambulatory day-surgery centers helps nurses and healthcare providers deliver optimal care to their patients. It also highlights the importance of tailoring preoperative preparations to the specific needs of patients undergoing same-day surgeries.

Correct Answer: D

Rationale: In preparation for ambulatory surgery, providing procedural information to patients is crucial for ensuring their understanding, cooperation, and overall positive outcomes. Option D, which includes information about what odors and sensations may be experienced, as well as techniques for coughing and deep breathing if appropriate, is the correct choice. Explaining potential odors and sensations helps to prevent anxiety or confusion during the surgery, while teaching coughing and deep breathing techniques can aid in postoperative recovery by preventing complications like atelectasis and pneumonia. Option A, while important, only addresses pain management, which is just one aspect of the preoperative education. Option B, fluid and food restrictions, is essential but primarily pertains to preoperative fasting guidelines rather than procedural information. Option C, characteristics of monitoring equipment, is more relevant to intraoperative or postoperative care and may not directly impact the patient's preparation for surgery. Educationally, understanding the rationale behind providing detailed procedural information to patients emphasizes the importance of holistic patient care, informed decision-making, and active patient engagement in their own health management. By empowering patients with knowledge, healthcare providers can enhance patient satisfaction, compliance, and outcomes in the perioperative setting.