While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Hematocrit.

Platelet count.

Creatinine level.

White blood cell (WBC) count.

Answer and Explanation

The Correct Answer is D

The presence of purulent drainage at the wound indicates a potential infection, and monitoring the client's WBC count is an important laboratory value to assess for signs of infection. An elevated WBC count, specifically an increase in the neutrophil count (neutrophilia), can indicate an active infection and provide important information for the healthcare provider when evaluating the wound.

While hematocrit, platelet count, and creatinine level are essential laboratory values to assess the client's overall condition, they may not provide specific information regarding the presence of infection or purulent drainage at the wound site.

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Correct Answer is C

Explanation

The correct answer is Choice C: “This must be a very difficult time for you.”

Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility.It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely 1.It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors 2. Therefore, it’s not something the parent did or didn’t do.

Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.

Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.

Choice D rationale: While it’s true that surgery can help manage the condition 1, saying “With surgery, your baby should have a full recovery” might be misleading.Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis 2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.

Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.

A. Obtain vital signs every 2 hours during hospitalization. B. Provide an eye shield to be worn while sleeping. C. Teach a family member to administer eye drops. D. Encourage deep breathing and coughing exercises.

Correct Answer is B

Explanation

After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.

This can help prevent inadvertent rubbing or bumping of the eye, which could potentially disrupt the surgical repair and hinder the healing process.

Obtaining vital signs every 2 hours during hospitalization is a routine nursing intervention for postoperative care in general but is not specific to retinal detachment surgery. The frequency of vital sign monitoring may vary depending on the client's overall condition and the healthcare provider's orders.

Teaching a family member to administer eye drops may be necessary for the client's ongoing care, but it is not specifically related to the immediate postoperative period. Eye drop administration instructions can be provided as part of the client's discharge teaching.

Encouraging deep breathing and coughing exercises is a general postoperative intervention that promotes respiratory function and helps prevent complications such as pneumonia. While important for overall postoperative care, it is not specific to retinal detachment surgery.

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While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Correct Answer is C

Explanation

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

Correct Answer is B

Explanation

Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

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The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?