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A nurse in an outpatient surgical center is assisting in the care of a client.

Exhibits
Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

WBC count

Pain

Abdominal findings

Blood type

Client's request for information

Blood pressure

Platelet count

Oxygen saturation

Client's PO intake

Capillary refill

Answer and Explanation

Correct Answer : B,E,F,H,I

A. The WBC count was not provided in the nurse’s notes or diagnostic section. Without any indication of infection or abnormal lab values, there is no basis to report WBC.

B. Although the pain level is mild (2/10), it may be contributing to anxiety, increased heart rate (110/min), and elevated BP (158/96 mm Hg). Report in context as part of a comprehensive assessment. Also, confirming that the pain is not worsening or atypical in nature is essential preoperatively.

C. The abdomen is soft, rounded, non-distended, with no tenderness, and active bowel sounds in all four quadrants — all normal postoperative readiness findings for abdominal surgery.

D. Knowing the blood type is routine pre-op procedure and is not an abnormal or urgent finding that needs immediate reporting. It is only relevant if transfusion is anticipated, which is not suggested here.

E. The client is requesting further details about the risks and benefits of surgery, which raises a legal and ethical concern about informed consent. The provider must ensure the client fully understands the procedure, otherwise surgery cannot proceed.

F. This is significantly elevated compared to baseline (126/74). Pre-op hypertension can increase surgical and anesthesia risk and should be evaluated further. It may be due to anxiety, pain, or another condition.

G. Platelet count values were not given in the scenario. Without abnormal lab results or bleeding concerns, there is no indication to report this.

H. This is lower than the previous baseline (97%). An SpO₂ < 94% on room air can signal underlying respiratory issues, atelectasis, sedation effects, or cardiac dysfunction, all of which should be addressed preoperatively.

I. The client ate breakfast at 0730 before a scheduled procedure, violating NPO (nothing by mouth) protocol. This significantly increases the risk of aspiration under anesthesia and must be reported immediately. The surgery may need to be rescheduled.

J. Capillary refill < 2 seconds is normal, indicating adequate peripheral perfusion. No issues with circulation are noted, so there's no reason to notify the provider.

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Correct Answer is B

Explanation

A. Speak with a loud voice while providing the information: Increasing the volume of speech is not effective for clients with expressive aphasia because their difficulty lies in producing language, not hearing. Speaking loudly may cause frustration or discomfort without improving communication.

B. Determine the client's ability to use a communication board: Assessing the client’s ability to use a communication board is an essential strategy to facilitate effective communication. Augmentative tools like communication boards can help them convey their needs and participate in teaching.

C. Provide the teaching without expecting the client to respond: Teaching without expecting any response can lead to missed opportunities for interaction and engagement. Encouraging some form of response, even nonverbal or through assistive devices, helps evaluate the client’s comprehension and maintains their involvement.

D. Avoid the use of facial gestures during the instructions: Facial gestures, body language, and visual cues play an important role in enhancing communication for clients with aphasia. Using expressive gestures should be encouraged to supplement verbal teaching and promote better comprehension.

A. Prick the side of the client's finger. B. Squeeze the client's finger until a blood drop forms. C. Elevate the client's hand above the level of the heart. D. Apply clean gloves. E. Cleanse the client's finger with an iodine swab.

Correct Answer is ["A","D"]

Explanation

A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.

B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.

C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.

D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.

E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.

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A nurse in an outpatient surgical center is assisting in the care of a client. Exhibits Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

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Explanation

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A nurse in an outpatient surgical center is assisting in the care of a client.

Exhibits
Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.