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 A

Explanation

A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.

A. Client educator B. Client advocate C. Client care provider D. Case manager

Correct Answer is C

Explanation

A. Client educator: Involves imparting knowledge or information to the client or others, which isn't the primary role of the nurse manager in this scenario.
B. Client advocate: Represents and supports the client's rights and needs.
C. Client care provider: The nurse manager is ensuring proper care provision by overseeing the procedure directly.
D. Case manager: Coordinates care and resources for the client's overall plan but isn't directly involved in overseeing a specific procedure.

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

Exhibits

Select the 4 findings that require immediate follow-up.