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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.
Choice B reason:
150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.
Choice C reason:
100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D reason:
200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.
Correct Answer is B
Explanation
Choice A Reason:
Decreased bowel sounds: Hyponatremia (low serum sodium levels) primarily affects the nervous system and can lead to neurological symptoms such as confusion, seizures, and headache. It doesn't typically directly affect bowel sounds. Therefore, this option is not the expected finding.
Choice B Reason:
Increased central venous pressure: As I mentioned earlier, hyponatremia can lead to cerebral edema (swelling of the brain) due to the movement of water into cells. This swelling can increase intracranial pressure and, in turn, affect the central venous pressure by impacting blood return to the heart. While the relationship between hyponatremia and central venous pressure might be complex, it's a more relevant consideration compared to the other options provided.
Choice C Reason:
Hyperreflexia: Hyponatremia can lead to changes in brain function and neurological symptoms, including altered reflexes. Hyperreflexia, which is an exaggerated response to stimuli, can indeed be a manifestation of hyponatremia, making this option a potential expected finding.
Choice D Reason:
Contusion: A contusion is a bruise that results from damage to blood vessels beneath the skin. Hyponatremia is not directly related to the formation of contusions. This option is not the expected finding in a client with low serum sodium levels.
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