A nurse is reviewing the medical record of a client who is 1-day post- operative following an appendectomy. Which of the following findings should the nurse report to the provider?
WBC count 8.400/mm3
Serosanguineous exudate noted on dressing change
Reports pain of 4 on a scale from 0 to 10 when coughing
Hemoglobin 10 mg/dL
The Correct Answer is D
Choice A reason:
WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.
Choice B reason:
Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.
Choice C reason:
Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.
Choice D reason:
Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Placing the client in high-Fowler's position is the appropriate action. When administering peritoneal dialysis, the nurse should place the client in a high-Fowler's position. This position helps promote the flow of dialysate into and out of the peritoneal cavity and assists with proper drainage. The high-Fowler's position allows for gravity to aid in the movement of fluid and helps prevent leakage of fluid back into the catheter.
Choice B Reason:
Chilling the dialysate before administration is not necessary and could cause discomfort to the client. Dialysate should be warmed to body temperature before use.
Choice C Reason:
Hanging the drainage bag below the client's abdomen is incorrect. The drainage bag should be positioned below the level of the abdomen to allow for proper drainage by gravity, but it should not be hung too low as this can lead to excessive drainage and dehydration.
Choice D Reason:
Using clean technique to access the catheter is incorrect. Sterile technique is required when accessing the peritoneal dialysis catheter to prevent infection. Peritoneal dialysis involves direct access to the peritoneal cavity, which is considered a sterile body cavity.
Correct Answer is A
Explanation
Choice A reason:
May operate a motor vehicle when no longer taking analgesics is appropriate. This option could still potentially be a concern. While the patient might not be taking analgesics, the halo device's restrictions on neck movement could still impact their ability to safely operate a motor vehicle. So, this option might still need clarification with the provider.
Choice B reason:
Increase Intake of fibre-rich foods. This option is not related to the use of a halo device. Increasing fibber intake is generally a positive dietary recommendation, and it doesn't directly pertain to the halo device or the patient's discharge instructions.
Choice C reason:
May place a small pillow under the head when sleeping. This option is incorrect because using a small pillow under the head when sleeping is a common practice for patients with halo devices. It helps to maintain proper alignment and reduce discomfort while sleeping.
Choice D reason:
Take tub baths instead of showers. This option is incorrect because taking tub baths instead of showers is a common recommendation for patients with halo devices. The halo device must be kept dry to prevent complications. Showering might increase the risk of water seeping into the halo vest, whereas taking a tub bath could help in maintaining dryness around the device.
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