A nurse is reviewing the medical record of a client who is 1-day post- operative following an appendectomy. Which of the following findings should the nurse report to the provider?
WBC count 8.400/mm3
Serosanguineous exudate noted on dressing change
Reports pain of 4 on a scale from 0 to 10 when coughing
Hemoglobin 10 mg/dL
The Correct Answer is D
Choice A reason:
WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.
Choice B reason:
Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.
Choice C reason:
Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.
Choice D reason:
Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Complete AV block with rates slower than 40/min Complete atrioventricular (AV) block, especially with rates slower than 40 beats per minute (bradycardia), is an indication for the placement of a permanent pacemaker. Complete AV block means there is a complete block in the electrical conduction between the atria and ventricles, resulting in a significant slowing or absence of impulses reaching the ventricles. This can lead to dangerously low heart rates and inadequate cardiac output.
Choice B reason:
Vasovagal bradycardia without syncope - Vasovagal bradycardia is often a temporary response to certain triggers (like pain or emotional stress) and does not typically require a permanent pacemaker.
Choice C reason:
Sinus tachycardia with rates faster than 80/min - Sinus tachycardia is a normal response to various factors, such as exercise, fever, or anxiety. It's not an indication for a permanent pacemaker.
Choice D reason:
Asymptomatic second-degree AV block - Asymptomatic second-degree AV block can be monitored and managed without a pacemaker, especially if the patient is not experiencing any symptoms or hemodynamic compromise. However, the type and severity of the second-degree AV block should be assessed by a healthcare provider to determine the appropriate course of action
Correct Answer is C
Explanation
Choice A reason:
Recommending staying at a local shelter might not be appropriate unless the client's health is in immediate danger due to the low temperature. It's better to explore other options first.
Choice B reason:
Contacting the client's family members about their financial status might not be necessary or respectful of the client's privacy without their consent.
Choice C reason:
Contact the local Department of Health and Human Services for the client. Contacting the local Department of Health and Human Services can help ensure that appropriate resources and assistance are provided to the client. They may have programs or services available to assist individuals who are struggling to afford heating during the winter. This action addresses the immediate concern of the client's health and the living environment.
Choice D reason:
Providing information about the dangers of hypothermia is important, but the client's current situation of living in a cold environment should be addressed first. The nurse can provide this information along with appropriate resources to help the client.
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