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 D

Explanation

A. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

A. Hold bottles of sterile solution with the label in the palm of the hand. B. Pour liquids into containers outside the sterile field. C. Place the sterile field at the level of the nurse's hips. D. Open the outermost flap of the sterile kit toward the body.

Correct Answer is A

Explanation

A. Holding bottles of sterile solution with the label in the palm of the hand can risk contamination as it involves touching the label. B. Pouring liquids into containers outside the sterile field helps prevent contamination of the field. C. Placing the sterile field at the level of the nurse's hips might not be optimal; it's typically positioned above waist level to maintain sterility. D. Opening the outermost flap of the sterile kit toward the body minimizes the risk of the flap touching non-sterile surfaces during opening.

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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

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is A

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.

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

Exhibits

Select the 4 findings that require immediate follow-up.