A nurse in an outpatient surgical center is assisting in the care of a client.
WBC count
Pain
Abdominal findings
Blood type
Client's request for information
Blood pressure
Platelet count
Oxygen saturation
Client's PO intake
Capillary refill
Correct Answer : B,E,F,H,I
A. The WBC count was not provided in the nurse’s notes or diagnostic section. Without any indication of infection or abnormal lab values, there is no basis to report WBC.
B. Although the pain level is mild (2/10), it may be contributing to anxiety, increased heart rate (110/min), and elevated BP (158/96 mm Hg). Report in context as part of a comprehensive assessment. Also, confirming that the pain is not worsening or atypical in nature is essential preoperatively.
C. The abdomen is soft, rounded, non-distended, with no tenderness, and active bowel sounds in all four quadrants — all normal postoperative readiness findings for abdominal surgery.
D. Knowing the blood type is routine pre-op procedure and is not an abnormal or urgent finding that needs immediate reporting. It is only relevant if transfusion is anticipated, which is not suggested here.
E. The client is requesting further details about the risks and benefits of surgery, which raises a legal and ethical concern about informed consent. The provider must ensure the client fully understands the procedure, otherwise surgery cannot proceed.
F. This is significantly elevated compared to baseline (126/74). Pre-op hypertension can increase surgical and anesthesia risk and should be evaluated further. It may be due to anxiety, pain, or another condition.
G. Platelet count values were not given in the scenario. Without abnormal lab results or bleeding concerns, there is no indication to report this.
H. This is lower than the previous baseline (97%). An SpO₂ < 94% on room air can signal underlying respiratory issues, atelectasis, sedation effects, or cardiac dysfunction, all of which should be addressed preoperatively.
I. The client ate breakfast at 0730 before a scheduled procedure, violating NPO (nothing by mouth) protocol. This significantly increases the risk of aspiration under anesthesia and must be reported immediately. The surgery may need to be rescheduled.
J. Capillary refill < 2 seconds is normal, indicating adequate peripheral perfusion. No issues with circulation are noted, so there's no reason to notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Check the client's medical records to see which medications were recently administered:
While reviewing medications is important for understanding potential causes of hypoxia, it is not the immediate priority when a client’s oxygen saturation is low. Immediate assessment and intervention to improve oxygenation come first.
B. Notify the charge nurse of the client's condition: Notifying the charge nurse is important but should follow an initial assessment and attempt to address the problem. Immediate client reassessment takes precedence to determine the current status and possible interventions.
C. Review the client's most recent SaO2 level in the medical record: Checking prior oxygen saturation levels can provide context but does not directly address the acute finding of 88% saturation, which requires prompt evaluation and action.
D. Recheck the client's SaO2 level after having the client cough and clear their throat: This action directly addresses a common cause of transient hypoxia such as airway obstruction from secretions. Reassessment after clearing the airway is the priority to determine if oxygenation improves before escalating interventions.
Correct Answer is D
Explanation
A. "We can discuss this after completing the admission process." Delaying discussion about the client’s aggression may leave the partner feeling unheard and unsupported during an emotionally charged moment. Immediate acknowledgement is important to build trust and provide reassurance.
B. "Your partner is in the denial stage of grief." Verbal aggression is not typically linked to the denial stage of grief, which is more about avoidance or disbelief. Aggression is more often related to frustration, fear, or physiological changes at end of life.
C. "You should discuss this problem with your family members." Redirecting the partner to family members does not address their concerns directly and can seem dismissive. The nurse should provide direct support and clear information to help the partner understand the client’s behavior.
D. "Your partner is experiencing an expected response to the dying process." Verbal aggression can be a normal reaction to the stress, pain, or neurological changes associated with the dying process. Providing this explanation helps normalize the behavior, reducing anxiety for the partner and promoting understanding.
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