A nurse is caring for a client who is scheduled for a surgical procedure

Exhibits

Select the 4 findings that require immediate follow-up.

Latex allergy

Hct level

Prothrombin time

WBC count

Preoperative medication

History of weekly exercise

Answer and Explanation

Correct Answer : B,C,D,E

A.   Although important, the client's allergy to latex might have been already noted, and it may not require immediate follow-up at this moment.
B.   A hematocrit of 37% is at the lower end of the normal range (37% to 47%). However, before a surgical procedure, it's crucial to ensure the client's blood volume is adequate, hence requiring immediate follow-up.
C.   A prothrombin time of 21 seconds (normal range: 11 to 12.5 seconds) indicates potential issues with blood clotting and requires prompt attention before surgery.
D.   A white blood cell count of 12,000/mm3 (normal range: 5,000 to 10,000/mm3) suggests an elevated count, which may indicate an infection or an inflammatory response, requiring immediate follow-up.
E.   The recent intake of aspirin (80 mg) might affect the client's clotting ability. It's essential to address this before the surgical procedure.
F.   While exercise history is relevant for overall health assessment, it may not require immediate action before the surgical procedure, considering other critical factors in the scenario.

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Correct Answer is ["C","D","F"]

Explanation

A. Mini Nutritional Assessment screening tool score: While it indicates the risk of malnutrition, it's not directly linked to delayed wound healing.
B. History of hyperlipidemia: Hyperlipidemia itself doesn't directly affect wound healing.
C. History of malnutrition: Malnutrition significantly hampers the body's ability to heal wounds effectively.
D. History of diabetes mellitus: Diabetes can impair wound healing due to poor blood sugar control affecting the immune system and circulation.
E. Cholesterol level: Elevated cholesterol, while relevant to overall health, is not directly linked to delayed wound healing.
F. Prealbumin level: Prealbumin is a marker for nutritional status; lower levels indicate inadequate protein intake and can contribute to delayed wound healing.

A. There is an area rug covering a tile floor. B. Grab bars are installed in the shower. C. Prescriptions are stored in a medication organizer. D. The hot water heater is set to 47° C (117" F).

Correct Answer is A

Explanation

A: The presence of an area rug over a tile floor poses a tripping hazard, which is particularly dangerous for individuals with osteoporosis due to the increased risk of fractures from falls. The rug can easily slip or edges can curl, leading to potential accidents. Therefore, it is crucial for the nurse to address this issue to prevent falls.

B: Grab bars in the shower are a safety feature that assists individuals in maintaining balance and preventing slips, which is beneficial for a person with osteoporosis. There is no need for intervention as this is a recommended safety measure.

C: Storing prescriptions in a medication organizer is a good practice as it helps ensure that medications are taken correctly and on time. This is especially important for older adults who may have multiple prescriptions. Thus, no intervention is needed here.

D: Setting the hot water heater to 47° C (117° F) can pose a risk of burns, especially for older adults whose skin may be more sensitive and who may have a delayed reaction to withdraw from hot surfaces. However, this is not directly related to osteoporosis, and while it is a safety concern, it is not as immediately hazardous as a tripping risk.

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A nurse is caring for a client who is scheduled for a surgical procedure Exhibits Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["C","D","F"]

Explanation

A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

Correct Answer is A

Explanation

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A nurse is caring for a client who is scheduled for a surgical procedure

Exhibits

Select the 4 findings that require immediate follow-up.