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

Answer and Explanation

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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Correct Answer is A

Explanation

Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.

A. A client who has a peripherally inserted central catheter (PICC) in the left arm B. A client who has a right upper extremity arteriovenous fistula C. A client who has right-sided weakness due to Parkinson's disease D. A client who has left-sided Bell's palsy

Correct Answer is B

Explanation

The nurse should obtain a blood pressure reading using only the left extremity from a client who has a right upper extremity arteriovenous fistula. An arteriovenous fistula is a surgical connection between an artery and a vein that is created for hemodialysis access.

Measuring blood pressure on the arm with an arteriovenous fistula can cause damage to the fistula, reduce blood flow, and increase the risk of infection or thrombosis. Therefore, blood pressure should be measured on the opposite arm or on another site such as the leg.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Correct Answer is A

Explanation

A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?

Correct Answer is B

Explanation

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