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.

Answer and Explanation

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

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Correct Answer is C

Explanation

C. Covering the patient with a warm blanket is an appropriate initial intervention to address the patient's hypothermia and shivering. Heat conservation measures, such as using blankets or warming devices, help raise the patient's body temperature and alleviate shivering.

A. While shivering and a low body temperature (hypothermia) can be common postoperative complications, holding opioid analgesics may not directly address the underlying cause of the shivering or hypothermia.

B. Notifying the anesthesia care provider is a prudent action, especially if the patient's shivering and hypothermia are suspected to be related to intraoperative factors such as inadequate warming or anesthesia-induced temperature dysregulation. However, this is not the immediate action.

D. Acetaminophen is not typically indicated as the initial treatment for hypothermia or shivering. While acetaminophen can help reduce fever and discomfort, rectal suppositories may not provide rapid temperature elevation or relief from shivering.

A. A client who has protein calorie malnutrition B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has right-sided heart failure and 4+ edema to the lower extremities D. A client who has postoperative delirium E. A client who is ambulatory following a cardiac catheterization 4 hr ago

Correct Answer is ["A"]

Explanation

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

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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;

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?

Correct Answer is C

Explanation

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Correct Answer is ["A"]

Explanation

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