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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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.

B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.

C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.

D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Answers:

Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client. Exhibits Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is dropdown followed by dropdown .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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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.