The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 x 103/μL;
hemoglobin 15 g/dL; hematocrit 45%; platelets 150 x 103/μL. Which action should the nurse
take?
Notify the surgeon and anesthesiologist immediately.
Ask the patient about any symptoms of a recent infection.
Continue to prepare the patient for the surgical procedure.
The Correct Answer is C
C. The client’s laboratory values are all within normal range. It is therefore, safe for the nurse to proceed with preparation for theatre.
A. Notifying the provider immediately is a preferred action in the case of any abnormal laboratory values of concern.
B. Questioning on the recent infection would be relevant if the white blood count is elevated which is not the case in this scenario.
D. The client’s hemoglobin is within normal range and therefore, no need for transfusion at this point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This technique helps to prevent pressure ulcers and assists in maintaining proper spinal alignment, which is essential after such a surgery.
B. Clear drainage on the spinal dressing is not typically expected and could indicate an infection or other complication.
C. Assisting the client to sit upright in a chair for extended periods is not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase.
D. Elevating the client's legs while sitting are not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase
Correct Answer is C
Explanation
C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.
A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.
B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.
D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.
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