A nurse is caring for a client who is scheduled for a surgical procedure
Select the 4 findings that require immediate follow-up.
Latex allergy
Hct level
Prothrombin time
WBC count
Preoperative medication
History of weekly exercise
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Metabolic syndrome is a cluster of conditions that include high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels, all of which increase the risk of cardiovascular disease.
B. Participation in competitive sports might enhance cardiovascular fitness and decrease the risk of cardiovascular diseases.
C. While alcohol use disorder can have health implications, it's not a direct risk factor for cardiovascular disease.
D. Hypotension (low blood pressure) is generally not considered a significant risk factor for cardiovascular disease, unlike hypertension (high blood pressure).
Correct Answer is ["A","C","D"]
Explanation
A. Assessing skin temperature and color is crucial to ensure circulation and skin integrity before applying restraints.
B. Attaching restraints to the bed rail isn't considered best practice, as it can lead to entrapment and injury.
C. Ensuring the client's bed is in the lowest position is essential to prevent falls and reduce the risk of injury if the client attempts to leave the bed.
D. Padding bony prominences helps prevent skin breakdown and discomfort.
E. Securing restraints to allow two fingers and not three,to slide under them ensures proper fit and prevents excessive tightness that could impair circulation.
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