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. Reporting any worsening or unrelieved pain is important because increasing or unrelieved pain could indicate complications such as inadequate immobilization, pressure sores, or compartment syndrome. Prompt reporting allows for timely intervention and prevention of further complications
B. Movement of the affected leg could disrupt the alignment of the bones and impede the healing process. Immobilization is essential for bone healing in a fiberglass cast. However, reporting features of compartment syndrome is priority.
C. Patients should be advised not to insert anything under the cast and instead use other methods such as blowing cool air under the cast or gently tapping on the outside of the cast to relieve itching.
D. Using a blow dryer on a moderate heat setting can help speed up the drying process of the cast after it gets wet. However, it's important to ensure that the heat is not too high to avoid causing burns or softening the cast material excessively.
Correct Answer is ["A","C","D"]
Explanation
A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.
C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.
D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.
B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.
E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.
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