While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion.
Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
Hematocrit.
Serum.
Blood PT level.
Neutrophil count.
The Correct Answer is D
Neutrophils are a type of white blood cell that play a key role in fighting infections.
An elevated neutrophil count can indicate the presence of an infection.
Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client’s neutrophil count.
Choice A is not correct because hematocrit is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.
Choice B is not correct because serum is not a laboratory value.
Choice C is not correct because blood PT level is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider. a
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Correct Answer is D
Explanation
Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client’s vital signs.
This includes checking the client’s blood pressure, pulse rate, respiratory rate, and temperature.
These measurements can provide important information about the client’s overall health status and can help the nurse determine if it is safe to proceed with the procedure.
Choice A is not correct because abdominal girth is not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice B is not correct because breath sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice C is not correct because bowel sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Correct Answer is C
Explanation
The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.
Choice A is not the answer because it is rude and unprofessional.
Choice B is not the answer because it does not address the issue of privacy and confidentiality.
Choice D is not the answer because it does not address the issue of privacy and confidentiality.
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