Difficulty: Medium
Average Score: 84%
Simulated
A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?
Correct answer
D
Rationale
Correct Answer: D - Raise the side rails on the bed.
Rationale: Raising the side rails on the bed is crucial post-administration of preoperative injection to ensure client safety and prevent falls. This action helps in maintaining the client's position and preventing accidental falls or injuries during the time when the client may still be under the effects of the injection. It also aligns with patient safety protocols in the perioperative setting.
Other Choices:
A: Taking the client to the bathroom to void is not necessary immediately after administering the preoperative injection.
B: Asking the client to verify the surgical site is important but may not be the immediate next step post-administration of the injection.
C: Reviewing deep breathing and coughing exercises is important for postoperative care but may not be the immediate next step after administering the injection.
Rationale: Raising the side rails on the bed is crucial post-administration of preoperative injection to ensure client safety and prevent falls. This action helps in maintaining the client's position and preventing accidental falls or injuries during the time when the client may still be under the effects of the injection. It also aligns with patient safety protocols in the perioperative setting.
Other Choices:
A: Taking the client to the bathroom to void is not necessary immediately after administering the preoperative injection.
B: Asking the client to verify the surgical site is important but may not be the immediate next step post-administration of the injection.
C: Reviewing deep breathing and coughing exercises is important for postoperative care but may not be the immediate next step after administering the injection.