A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
WBC count 8,400/mm3
Reports pain of 4 on a scale from 0 to 10 when coughing
Serosanguineous exudate noted on dressing change
Hemoglobin 10 mg/dL
The Correct Answer is D
This is a low hemoglobin level, which may indicate blood loss. The nurse should report this finding to the provider immediately, as it may require further investigation and intervention, such as blood transfusion.
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Related Questions
Correct Answer is D
Explanation
The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.
Correct Answer is B
Explanation
Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.
Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.
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