A nurse in an outpatient surgical center is assisting in the care of a client.
WBC count
Pain
Abdominal findings
Blood type
Client's request for information
Blood pressure
Platelet count
Oxygen saturation
Client's PO intake
Capillary refill
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Impaired hearing: Impaired hearing can increase the risk of injury by reducing the client’s ability to hear alarms or warnings. However, it is considered a sensory impairment rather than a lifestyle choice.
B. Reduced health literacy: Low health literacy can contribute to poor understanding of safety instructions and adherence to precautions, increasing injury risk. Nonetheless, it relates more to knowledge deficits than lifestyle behaviors.
C. Lower extremity weakness: Weakness in the legs increases fall risk due to impaired mobility and balance. This is a physical or functional risk factor rather than a lifestyle risk.
D. Texting while driving: Texting while driving is a high-risk lifestyle behavior directly associated with increased injury and accident rates. It involves voluntary behavior that compromises safety and is a preventable cause of injury.
Correct Answer is C
Explanation
A. Turn on loud music in client care areas: Loud music can increase noise levels, which contributes to environmental stress and can disrupt clients’ rest and recovery. It is generally contraindicated in acute care settings where reducing stress and promoting healing are priorities.
B. Assign different nurses to provide care for clients each day: Frequent changes in caregivers can increase client anxiety and stress by reducing continuity of care and trust. Consistent assignments promote familiarity, comfort, and better communication between clients and caregivers.
C. Restrict the number of visitors for clients: Limiting visitors helps reduce noise and overcrowding, which are common environmental stressors in acute care units. This strategy supports a calmer environment conducive to client rest and recovery while maintaining essential social support.
D. Offer the clients many choices regarding care: While offering choices can promote autonomy, providing too many options may overwhelm clients, especially those who are ill or stressed. Simplifying decisions helps reduce cognitive overload and environmental stress.
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