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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Assigning the newly hired unlicensed assistive personnel (UAP) to clients who require the least complex level of care is not the best approach to ensure adequate care for all clients. It may limit the UAP's opportunities for learning and growth and may not fully utilize their skills.
Choice B rationale:
Asking the most experienced UAP to partner with the newly hired UAP is a reasonable approach, but it may not provide a comprehensive solution. It can be beneficial for mentorship and guidance, but it may not address all the clients' needs efficiently.
Choice C rationale:
Reviewing the UAP's skills checklist and experience with the person who hired the UAP is an important step in assessing competency. However, it alone may not ensure adequate care for all clients. Competency assessment should be ongoing and include direct observation of care delivery.
Correct Answer is D
Explanation
The correct answer is: D. Blood pressure 90/76 mm Hg.
Clonidine is an alpha-2 adrenergic agonist used to manage withdrawal symptoms, but it lowers blood pressure as a side effect. If the client's blood pressure is already low (90/76 mm Hg), administering clonidine could lead to hypotension, putting them at risk for dizziness, fainting, or more severe complications.
Here's why the other options are not contraindications:
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A. Hypertension: Clonidine is actually used to treat high blood pressure, so it wouldn’t be a contraindication.
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B. Apical heart rate 72 beats/minute: This heart rate is within normal limits, so it wouldn’t prevent administration.
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C. Muscle weakness: While clonidine can cause fatigue, muscle weakness is not a direct contraindication.
Since the client is experiencing withdrawal symptoms like nervousness and unusual sensations ("bones itching"), monitoring vital signs is critical before giving the medication.
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