The client is in stage 2 of general anesthesia. What is the priority nursing intervention?
1. Insert a urinary catheter.
2. Maintain a quiet and calm environment in the operating room suite.
3. Administer a surgical scrub to the operative site.
4. Assist the anesthesiologist in positioning the client on the operating room table.
Correct Answer: 2
Rationale 1: The client is hyperexcitable in stage 2. Insertion of a urinary catheter is not appropriate in this stage.
Rationale 2: The client is hyperexcitable in stage 2. Therefore, the environment must be kept quiet to minimize stimulation.
Rationale 3: Providing a surgical scrub is not appropriate in this stage as the client is in a hyperexcitable state.
Rationale 4: Positioning the client is not appropriate during this stage as the client is hyperexcitable.
Global Rationale: The client is hyperexcitable in stage 2. Therefore, the environment must be kept quiet to minimize stimulation. Insertion of a urinary catheter, providing a surgical scrub, and positioning the client are not appropriate in stage 2.
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