The nurse is continuing to assist in the care of the client post-surgery. The test-taker must interpret the following exhibits to answer the question.

The nurse is assisting with evaluating the client’s responses to interventions.

Exhibits
Based on the exhibits and findings, which findings indicate that the client’s condition is improving? Select all that apply

Oxygen saturation

Hemoglobin

Mental status

Urinary output

WBC count

Answer and Explanation

Correct Answer : C,E

Choice A rationale:

Oxygen saturation is not provided in the exhibits, so there is no data available to evaluate if it indicates improvement in the client’s condition. While oxygen saturation is an important indicator of respiratory function and overall oxygenation status, its absence means it cannot be used to assess the client’s progress in this case.

Choice B rationale:

Hemoglobin levels decreased from 14 g/dL on postoperative day 1 to 10.5 g/dL on postoperative day 2. This decline in hemoglobin levels suggests that the client may be experiencing blood loss or anemia, which is not indicative of improvement. Generally, an improvement in the client’s condition would be reflected in stable or increasing hemoglobin levels rather than a decrease.

Choice C rationale:

Mental status is an important indicator of overall recovery and improvement. On postoperative day 2, the client is described as drowsy but alert to voice. This level of responsiveness indicates an improvement in mental status compared to what might be expected immediately post-surgery. A client who is drowsy but still responsive to verbal stimuli is showing signs of regaining consciousness and cognitive function, which is a positive sign of recovery.

Choice D rationale:

Urinary output is not provided in the exhibits, so there is no data available to assess if it indicates improvement. Urinary output is an important measure of kidney function and fluid status, but without specific data, it cannot be used to determine the client’s progress.

Choice E rationale:

The WBC count increased from 7,000/mm³ on day 1 to 8,500/mm³ on day 2, which is within the normal range and indicates a healthy immune response.

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Correct Answer is ["1.5"]

Explanation

Step 1: Identify the order. The order is for 15,000 units of heparin.

Step 2: Identify the available medication. The available medication is heparin 10,000 units/mL.

Step 3: Calculate the dose. To find out how many mL to administer, divide the number of units ordered by the number of units per mL. So, 15,000 units ÷ 10,000 units/mL = 1.5 mL. So, the nurse should administer 1.5 mL of heparin with each dose.

A. Scheduled times for dressing changes. B. Primary health problem. C. Admission vital signs from 1 week ago. D. Current medication prescriptions. E. Number of family members who have visited.

Correct Answer is ["B","D"]

Explanation

Choice A rationale

Scheduled times for dressing changes are not typically included in transfer documentation. This information is usually part of the patient’s daily care plan and can be communicated to the receiving unit as needed.

Choice B rationale

The primary health problem is crucial information to include in the transfer documentation. It provides the receiving unit with a clear understanding of the patient’s main health issue and the reason for their transfer.

Choice C rationale

Admission vital signs from 1 week ago are not typically included in transfer documentation. The most recent vital signs are more relevant and provide a better indication of the patient’s current health status.

Choice D rationale

Current medication prescriptions are essential to include in the transfer documentation. This information ensures continuity of care and prevents medication errors.

Choice E rationale

The number of family members who have visited is not typically included in transfer documentation. This information is not directly related to the patient’s health status or care needs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin 15,000 units every 12 hr subcutaneously to a client who weighs 80 kg. Available is 10,000 units/mL. How many mL should the nurse administer with each dose?

Correct Answer is ["1.5"]

Explanation

A nurse is assisting with the transfer of a patient from a medical-surgical unit to an intensive care unit following a change in status.What information should the nurse include in the transfer documentation? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

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