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:
A calcium level of 11.5 mg/dL is elevated. Normal calcium levels typically range from 8.5 to 10.5 mg/dL. Hypercalcemia can lead to various complications, including cardiac arrhythmias and neurological symptoms. The nurse should notify the provider of this finding for further evaluation and management.Choice B reason
Serum albumin level 3.9 g/dL is not appropriate. This level is within a reasonable range for serum albumin. It might be an indicator of nutritional status, but it's not an urgent concern.
Choice C reason:
Output exceeding intake over a 12-hour period may indicate fluid imbalance or inadequate intake compared to output. However, without further context, such as the client's overall fluid status, this finding alone may not be alarming. The nurse should assess the client's hydration status, consider potential causes of increased output, and address any concerns accordingly. While the nurse may need to monitor closely and address any potential issues, immediate notification of the provider may not be necessary based solely on this finding.Choice D reason:
Fasting blood glucose level 105 mg/dL is not appropriate: A fasting blood glucose level of 105 mg/dL is slightly elevated, but it's not a critically high value. The nurse should monitor blood glucose levels and collaborate with the healthcare team to manage blood glucose appropriately.
However, if the client has a history of diabetes or if there are other concerning factors, such as consistent high glucose levels or symptoms of hyperglycemia, the nurse may need to monitor closely and notify the provider for further evaluation and management. Otherwise, this finding alone may not warrant immediate notification.Correct Answer is D
Explanation
Choice A Reason:
Increased potassium level is incorrect. Valsartan does not typically cause an increase in potassium levels.
Choice B Reason:
Decreased urinary output is incorrect. Valsartan is not directly associated with changes in urinary output.
Choice C Reason:
Increased heart rate is incorrect. Valsartan generally does not lead to an increased heart rate; it is more likely to help regulate heart rate and reduce strain on the heart.
Choice D Reason:
Decreased blood pressure is correct. Valsartan is an angiotensin II receptor blocker (ARB) commonly used to treat conditions such as heart failure and hypertension. One of its primary effects is to dilate blood vessels and lower blood pressure. Therefore, a decreased blood pressure would indicate that the medication is effective in achieving its therapeutic goal of reducing the workload on the heart and improving circulation.
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