Which data is cause for immediate intervention for a client after a right shoulder replacement?
Creatinine level is 0.8 mg/dL.
Potassium level is 4.2 mEq/L.
White blood cell count is 9,000 mm³.
Hemoglobin is 7.1 g/dL.
The Correct Answer is D
Choice A Reason
A creatinine level of 0.8 mg/dL falls within the normal range for adults, which is typically 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates normal kidney function and is not a cause for immediate intervention post-operatively.
Choice B Reason
A potassium level of 4.2 mEq/L is within the normal range, which is generally between 3.6 and 5.2 mEq/L. This level indicates a stable electrolyte balance and is not a cause for immediate concern following shoulder replacement surgery.
Choice C Reason
A white blood cell (WBC) count of 9,000 mm³ is within the normal range, which typically spans from 4,500 to 11,000 WBCs per mm³. This suggests there is no active infection or inflammation that requires immediate intervention.
Choice D Reason
A hemoglobin level of 7.1 g/dL is considered low, as the normal range for adult males is generally 13.8 to 17.2 g/dL and for adult females is 12.1 to 15.1 g/dL. Low hemoglobin can indicate anemia, which may be due to blood loss during surgery or other underlying conditions. This requires immediate intervention to address potential oxygenation issues and determine the cause of the anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
Taking alprazolam with food may help with some gastrointestinal side effects but does not address the client's concerns about dizziness and light-headedness. While it is a practical suggestion, it is not the priority response when the client is experiencing symptoms that could affect their safety¹.
Choice B Reason
The priority for the nurse is to ensure the client's safety. Dizziness and light-headedness can increase the risk of falls or accidents, especially when performing tasks that require alertness, such as driving or operating machinery. Therefore, advising the client to avoid dangerous activities is the most immediate and appropriate response¹.
Choice C Reason
While it is true that alprazolam is often prescribed for short-term use and some side effects may diminish over time, this does not provide the client with a solution to their current symptoms. The nurse should address the client's immediate concerns and ensure their safety before discussing the duration of medication use¹.
Choice D Reason
Using sugarless gum or candy can help with dry mouth, which is a common side effect of alprazolam. However, this advice does not address the more serious side effects of dizziness and light-headedness that the client is experiencing. Therefore, it is not the priority response but can be included as additional advice¹.
Correct Answer is C
Explanation
Choice A Reason
Metoprolol, a beta-blocker, can cause fluid retention, which may lead to swelling in the ankles. However, this is not a common side effect and is not typically included as a standard warning for patients starting on metoprolol. Patients should be aware of this potential side effect but also understand that it may not occur.
Choice B Reason
Patients should not stop taking metoprolol abruptly, especially if they experience fatigue, which can be a common side effect. Abrupt cessation can lead to rebound hypertension or angina. Instead, patients should consult their healthcare provider if they experience significant fatigue that impacts their daily activities.
Choice C Reason
Checking the pulse is an important self-monitoring measure for patients on metoprolol. This medication can slow the heart rate, and patients should be instructed on how to check their pulse and what to do if it falls below a certain rate, as advised by their healthcare provider.
Choice D Reason
While staying hydrated is generally good advice, there is no specific need to drink plenty of fluids related to the use of metoprolol for angina pectoris. Patients should follow normal hydration guidelines unless otherwise directed by their healthcare provider.
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