A nurse is reviewing the diagnostic test results of a female client who is about to undergo knee arthroplasty. Which of the following data collection findings should the nurse identify as the priority?

Creatinine 0.9 mg/dL

WBC count 20,000/mm3

Potassium 3.8 mEq/L

Hematocrit 40%

Answer and Explanation

The Correct Answer is B

a. Creatinine 0.9 mg/dL: This creatinine level is within the normal range and is not an immediate priority for knee arthroplasty.

b. WBC count 20,000/mm3: An elevated white blood cell count suggests the presence of

infection or inflammation. In the context of knee arthroplasty, infection is a significant concern and requires immediate attention to prevent complications.

c. Potassium 3.8 mEq/L: This potassium level is within the normal range and is not an immediate priority for knee arthroplasty.

d. Hematocrit 40%: This hematocrit level is within the normal range and is not an immediate priority for knee arthroplasty. The elevated WBC count takes precedence as it suggests a

potential infectious process.

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Correct Answer is B

Explanation

a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.

b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces

should not be present in the drainage appliance. This finding could indicate a complication and should be reported.

c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.

d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.

A. Hyperactive bowel sounds B. Increased urine output C. Hypotension D. Bradycardia

Correct Answer is C

Explanation

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.

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A nurse is reviewing the diagnostic test results of a female client who is about to undergo knee arthroplasty. Which of the following data collection findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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