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","B","C"]

Explanation

A. Using grab bars enhances safety while bathing.
B. Having a fire escape plan contributes to home safety.
C. Checking medication expiration dates ensures safe and effective use.
D. Setting the water heater to 140 degrees Fahrenheit may pose a scalding risk.
E. Applying tape to electrical cords is not a safe practice and does not indicate an understanding of safety precautions.

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Recheck the client's BP in her other arm for comparison. C. Request that another nurse check the client's BP in 30 min. D. Reposition the client supine and recheck her BP.

Correct Answer is B

Explanation

A: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.

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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

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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.