A nurse is caring for a client who is scheduled for a surgical procedure

Exhibits

Select the 4 findings that require immediate follow-up.

Latex allergy

Hct level

Prothrombin time

WBC count

Preoperative medication

History of weekly exercise

Answer and Explanation

Correct Answer : B,C,D,E

A.   Although important, the client's allergy to latex might have been already noted, and it may not require immediate follow-up at this moment.
B.   A hematocrit of 37% is at the lower end of the normal range (37% to 47%). However, before a surgical procedure, it's crucial to ensure the client's blood volume is adequate, hence requiring immediate follow-up.
C.   A prothrombin time of 21 seconds (normal range: 11 to 12.5 seconds) indicates potential issues with blood clotting and requires prompt attention before surgery.
D.   A white blood cell count of 12,000/mm3 (normal range: 5,000 to 10,000/mm3) suggests an elevated count, which may indicate an infection or an inflammatory response, requiring immediate follow-up.
E.   The recent intake of aspirin (80 mg) might affect the client's clotting ability. It's essential to address this before the surgical procedure.
F.   While exercise history is relevant for overall health assessment, it may not require immediate action before the surgical procedure, considering other critical factors in the scenario.

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Correct Answer is C

Explanation

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

A. Heart rate B. Blood pressure C. Temperature D. Urticaria E. Swollen tongue F. Breath sounds

Correct Answer is ["B","D","E","F"]

Explanation

A. While elevated (104/min), it's essential, but not as critical as other findings.
B. The significant drop in blood pressure from 108/56 mm Hg to 88/56 mm Hg within 30 minutes is a cause for immediate concern.
C. The slight increase in temperature (from 37.6°C to 37.5°C) is important but not the most pressing concern.
D. Itching over the chest with urticaria (hives) suggests an allergic reaction, requiring urgent attention.
E. Swelling of the tongue is a severe sign of an allergic reaction and requires immediate intervention.
F. Clear and present breath sounds with scattered wheezing indicate potential airway compromise, requiring immediate follow-up.

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A nurse is caring for a client who is scheduled for a surgical procedure Exhibits Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is ["B","D","E","F"]

Explanation

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A nurse is caring for a client who is scheduled for a surgical procedure

Exhibits

Select the 4 findings that require immediate follow-up.