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 A

Explanation

The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.

Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.

Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

Correct Answer is A

Explanation

A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.

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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

Correct Answer is A

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is A

Explanation

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