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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","D","E"]

Explanation

A. Room number: Room number is not a reliable client identifier because clients can be moved or rooms reassigned, which increases the risk of medication errors or misidentification.

B. Photo identification: Using photo identification is a reliable way to confirm the client’s identity, ensuring that medications are given to the correct person by visually matching the client’s face.

C. Diagnosis: Diagnosis alone is not a unique identifier since multiple clients can share the same diagnosis, and it does not confirm identity for medication administration purposes.

D. Facility-assigned identification number: This number is a unique identifier assigned to each client and is commonly used in healthcare settings to verify identity accurately before medication administration.

E. Date of birth: Date of birth is a reliable identifier to cross-check client identity, especially when used with other identifiers, reducing the risk of errors during medication administration.

A. Scrubs hands with antibacterial soap for 10 seconds B. Washes his hands under hot running water C. Uses firm, circular motions to wash his hands D. Dries his hands from the forearms to the fingers

Correct Answer is C

Explanation

A. Scrubs hands with antibacterial soap for 10 seconds: The recommended duration for effective handwashing is at least 20 seconds to ensure adequate removal of microbes and reduce infection risk. Washing for only 10 seconds is insufficient to properly cleanse the hands.

B. Washes his hands under hot running water: Using hot water can cause skin irritation and dryness, which may lead to compromised skin integrity. Warm or cold water is recommended as it effectively removes germs without damaging the skin.

C. Uses firm, circular motions to wash his hands: Using firm, circular motions ensures thorough cleansing of all hand surfaces, including between fingers and around nails. This technique promotes effective removal of dirt and microorganisms and is consistent with hand hygiene best practices.

D. Dries his hands from the forearms to the fingers: Drying should always proceed from the fingertips toward the forearms to prevent recontamination of clean hands. Drying from forearms to fingers can transfer contaminants back to the hands, defeating the purpose of handwashing.

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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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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.