Page 506 - Saunders Comprehensive Review For NCLEX-RN

Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Perioperative Care
Health Problem: Adult Health: Hematological: Anemias
Priority Concepts: Clinical Judgment; Collaboration
Reference: Lewis et al. (2017), p. 600.

137. Answer: 1

Rationale: The first action of the nurse is to assess the patency of the airway and
respiratory function. If the airway is not patent, the nurse must take immediate
measures for the survival of the client. The nurse then takes vital signs followed by
checking the dressing and the tubes or drains. The other nursing actions should be
performed after a patent airway has been established.
Test-Taking Strategy: Note the strategic word, first. Use the principles of
prioritization to answer this question. Use the ABCs—airway, breathing, and
circulation. Ensuring airway patency is the first action to be taken, directing you to
the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Foundations of Care: Perioperative Care
Health Problem: N/A
Priority Concepts: Care Coordination; Clinical Judgment
Reference: Lewis et al. (2017), p. 331.

138. Answer: 1

Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids
cause adrenal atrophy, which reduces the ability of the body to withstand stress.
When stress is severe, corticosteroids are essential to life. Before and during surgery,
dosages may be increased temporarily and may be given parenterally rather than
orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency
anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an
estrogen used for hormone replacement therapy in postmenopausal women. These
last 3 medications may be withheld before surgery without undue effects on the
client.
Test-Taking Strategy: Focus on the subject, the medication that should be
administered in the preoperative period. Use knowledge about medications that
may have special implications for the surgical client. Prednisone is a corticosteroid.
Recall that when stress is severe, such as with surgery, corticosteroids are essential to
life.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Foundations of Care: Perioperative Care

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