A nurse is caring for a client who is scheduled for a surgical procedure
Select the 4 findings that require immediate follow-up.
Latex allergy
Hct level
Prothrombin time
WBC count
Preoperative medication
History of weekly exercise
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Delivering a series of high-pitched sounds at random intervals is not related to the Weber's test.
B. Weber's testis performed by striking the tuning fork and placing it against the middle of the forehead. Ask the patient if the tone is equal in both ears. Diminution in the affected ear indicates sensorineural hearing loss.
C. Placing an activated tuning fork on the client's mastoid process is not part of the Weber's test.
D. Whispering a series of words softly into one ear is unrelated to the Weber's test; it's a test for assessing auditory acuity.
Correct Answer is A
Explanation
Rationale for A: Area rugs pose a significant tripping hazard for older adults, especially for those with osteoporosis who are at an increased risk for fractures if they fall. The nurse should intervene by advising the client to remove the area rug to prevent falls.
Rationale for B: Grab bars installed in the shower are a safety feature that helps prevent falls, especially for clients with mobility issues. This is a positive finding and does not require intervention.
Rationale for C: Storing prescriptions in a medication organizer helps the client keep track of their medications and prevents confusion, especially in older adults. This is an effective way to manage medications and does not need intervention.
Rationale for D: The hot water heater set to 47°C (117°F) is within the safe range to prevent burns while still providing sufficient warmth for bathing. This does not pose a risk to the client, and no intervention is needed.
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