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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason:

Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or

Choice B reason:

Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.

Choice C reason:

Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.

Choice D reason:

Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.

A. Reposition the client's left arm. B. Check the IV site for redness. C. Ensure the tubing connections are secure. D. Flush the IV catheter

Correct Answer is C

Explanation

Choice A Reason:

Repositioning the client's left arm is incorrect. Repositioning the arm might help prevent kinks or occlusions in the tubing, but addressing the tubing connections comes first.

Choice B Reason:

Checking the IV site for redness is incorrect. Checking for redness is important to assess for signs of infection or inflammation, but it can wait until after addressing the tubing issue.

Choice C Reason:

Ensuring the tubing connections are secure is correct. When the infusion pump alarms, the first step is to ensure that the tubing connections are secure. A loose or disconnected tubing can lead to interrupted or inadequate infusion, which could affect the client's treatment and well-being. By checking and securing the tubing connections, the nurse can address any immediate issues related to the alarm.

Choice D Reason:

Flushing the IV catheter is incorrect - Flushing the catheter might be necessary if there are blockages or if medications need to be administered, but addressing the tubing connections is the immediate priority when the infusion pump alarms.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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