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 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.
Correct Answer is A
Explanation
A. Bowel cleansing is often required prior to an intravenous pyelogram to remove fecal matter that can obscure visualization of the urinary tract. A clear field improves the accuracy of imaging and helps ensure diagnostic quality.
B. Removing metal objects is important for procedures such as MRI or X-rays of certain areas, but it is not the primary preparation specific to an intravenous pyelogram. The focus is on visualization of the urinary system using contrast.
C. Intravenous pyelogram involves the administration of contrast dye intravenously, not orally. Giving oral contrast is associated with gastrointestinal imaging studies, not urinary tract imaging.
D. Monitoring for suprapubic pain is not a routine or priority nursing action specific to this procedure. Post-procedure care focuses more on monitoring for contrast reactions and ensuring adequate hydration.
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