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

Serum sodium level.

Hematocrit.

Neutrophil count.

Platelet count.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.

Choice B rationale:

Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

Choice C rationale:

Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

Choice D rationale:

Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

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Correct Answer is B

Explanation

The correct answer is choice b. Respiratory alkalosis.

Choice A rationale:

Metabolic alkalosis occurs when there is a loss of acid or an increase in bicarbonate in the body. This can be due to vomiting, diuretic use, or excessive bicarbonate intake. It is not typically associated with hyperventilation.

Choice B rationale:

Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide (CO2) levels in the blood. This condition is often triggered by anxiety, fear, pain, or fever, all of which are present in this adolescent.

Choice C rationale:

Metabolic acidosis occurs when there is an accumulation of acid or a loss of bicarbonate in the body. This can be due to conditions like diabetic ketoacidosis, renal failure, or severe diarrhea. It is not typically associated with hyperventilation.

Choice D rationale:

Respiratory acidosis occurs when there is an accumulation of CO2 in the blood due to hypoventilation or impaired lung function. This condition is not consistent with hyperventilation, which reduces CO2 levels.

A. Ask the wife to stop and assess the client's swallowing reflex. B. Give the wife a straw to help facilitate the client's drinking. C. Assist the wife and carefully give the client small sips of water. D. Obtain thickening powder before providing any more fluids.

Correct Answer is A

Explanation

The correct answer is choice a. Ask the wife to stop and assess the client’s swallowing reflex.

Choice A rationale:

Assessing the client’s swallowing reflex is crucial because facial paralysis and inability to move one side can indicate a risk of aspiration. Ensuring the client can safely swallow before giving any fluids is a priority to prevent complications like aspiration pneumonia.

Choice B rationale:

Giving the wife a straw might seem helpful, but it does not address the underlying risk of aspiration. Without assessing the swallowing reflex, using a straw could still lead to aspiration.

Choice C rationale:

Assisting the wife in giving small sips of water without assessing the swallowing reflex first is unsafe. The client might not be able to swallow properly, increasing the risk of aspiration.

Choice D rationale:

Obtaining thickening powder is a good step for clients with swallowing difficulties, but it should be done after assessing the swallowing reflex. The priority is to first determine if the client can swallow safely.

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While changing a client's postoperative dressing, the nurse observes purulent drainage at the site.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

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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