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A nurse in an outpatient surgical center is assisting in the care of a client.

Exhibits
Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

WBC count

Pain

Abdominal findings

Blood type

Client's request for information

Blood pressure

Platelet count

Oxygen saturation

Client's PO intake

Capillary refill

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "I will keep the drainage bag below the level of my waist.": Keeping the drainage bag below the waist or bladder level is essential to prevent backflow of urine, which can lead to infection or bladder distention. This practice promotes proper drainage by gravity and helps reduce the risk of urinary tract infections.

B. "I will apply antiseptic ointment to the tip of my penis.": Applying antiseptic ointment is generally not recommended unless specifically prescribed by a healthcare provider. Routine use of ointments can irritate the urethral area or disrupt normal flora, potentially increasing infection risk.

C. "I will empty my drainage bag once a day.": Emptying the drainage bag only once daily is insufficient and increases the risk of urinary stasis and infection. The bag should be emptied regularly, at least every 8 hours or when it is two-thirds full, to maintain proper flow and reduce bacterial growth.

D. "I will clamp the tube when I go for a walk.": Clamping the catheter tubing can cause urine retention and increase the risk of bladder overdistention and infection. The tubing should remain open to allow continuous drainage regardless of activity level to ensure bladder emptying and prevent complications.

A. "We can discuss this after completing the admission process." B. "Your partner is in the denial stage of grief." C. "You should discuss this problem with your family members." D. "Your partner is experiencing an expected response to the dying process."

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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A nurse in an outpatient surgical center is assisting in the care of a client. Exhibits Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

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A nurse in an outpatient surgical center is assisting in the care of a client.

Exhibits
Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.