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 C
Explanation
Choice A Reason:
The client reports being extremely thirsty with a sore throat - This could be due to the presence of the NG tube and suctioning, but it is not as immediately concerning as the change in drainage colour.
Choice B Reason:
The client's abdomen becomes distended and firm - While this could indicate a possible complication, it is not as directly related to the change in drainage colour.
Choice C Reason:
The drainage is bright green in colour with brown faecal material the finding that the drainage from the NG tube is bright green in colour with brown faecal material should be reported to the provider. This change in the colour and appearance of the drainage can be indicative of bilious (greenish-yellow) vomiting, which may suggest an obstruction or another underlying issue. It's important to assess the client's condition and inform the provider about any significant changes in their symptoms.
Choice D Reason:
The amount of drainage is gradually decreasing - Gradually decreasing drainage could be expected as the condition improves, but it's not as alarming as a change in the drainage colour.
Correct Answer is D
Explanation
Choice A Reason:
Applying lotion between the toes - Applying lotion between the toes can create a moist environment that may increase the risk of fungal infections. Lotion application should be done on the tops and bottoms of the feet, avoiding the spaces between the toes.
Choice B Reason:
Inspecting the feet every other day - Daily foot inspections are recommended for individuals with diabetes to identify any changes or abnormalities early and prevent potential complications.
Choice C Reason:
Soaking the feet twice a day - Excessive soaking of the feet can lead to maceration of the skin and increase the risk of infection, so it's generally not recommended. Regular washing with mild soap and water is sufficient for foot hygiene.
Choice D Reason
Trim toenails straight across When providing discharge teaching about foot care to a client with diabetes, the nurse should include information about proper foot care practices to prevent complications. Trimming toenails straight across is recommended to avoid ingrown toenails and potential injury. This reduces the risk of foot complications that can arise due to diabetes-related circulatory and neuropathic changes.
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