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 C

Explanation

Choice A rationale:

The nurse should respect the client's autonomy and right to make decisions about her own care. It is essential to honor the client's refusal of further treatment, and the nurse should communicate this to the family. In this situation, the client has the capacity to make her own decisions, and her wishes should be respected.

Choice B rationale:

Attempting to persuade the client to participate in the clinical trial for one month is not an appropriate approach. It disregards the client's autonomy and her right to refuse treatment. It's essential to respect the client's decision, and trying to convince her against her will is ethically and legally inappropriate.

Choice D rationale:

While it's important to ensure that the client fully understands the implications of her decision, doing so in front of her children may create additional pressure or discomfort for the client. The best approach is to have a private conversation with the client to assess her understanding and provide information or support as needed.

A. Release the client as soon as composure is regained. B. Observe for extrapyramidal symptoms, such as dystonia. C. Secure the room with padded walls and minimal furnishings. D. Provide one-on-one observation at all times.

Correct Answer is B

Explanation

Choice B rationale:
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential to cause extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.
Choice A rationale:
Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.
Choice C rationale:
Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.
Choice D rationale:
Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.

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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

Correct Answer is C

Explanation

Correct Answer is B

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?