The nurse is reviewing laboratory results for a patient scheduled for a cholecystectomy. Which result is most important for the nurse to report to the surgeon?

Blood glucose level of 90 mg/dL (5 mmol/L).

Serum creatinine level of 5 mg/dL (442 µmol/L).

Hemoglobin level of 13 g/dL (130 g/L).

Potassium level of 4 mEq/L (4 mmol/L).

Answer and Explanation

The Correct Answer is B

Choice A rationale
A blood glucose level of 90 mg/dL (5 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Choice B rationale
A serum creatinine level of 5 mg/dL (442 µmol/L) is significantly elevated, indicating impaired kidney function. This is a critical lab value that should be reported to the surgeon immediately, as it could impact the patient’s ability to safely undergo surgery and recover postoperatively.

Choice C rationale
A hemoglobin level of 13 g/dL (130 g/L) is within the normal range and would not need to be reported to the surgeon.
Choice D rationale
A potassium level of 4 mEq/L (4 mmol/L) is within the normal range and would not need to be reported to the surgeon.

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Correct Answer is C

Explanation

Choice A rationale
While obtaining a serum drug screen might be helpful in confirming the presence of benzodiazepines or other substances, it is not the most immediate concern in a client experiencing severe agitation and tremors due to withdrawal.
Choice B rationale
Naloxone is an opioid antagonist and would not be effective in managing withdrawal symptoms from benzodiazepines.
Choice C rationale
Seizure precautions should be initiated as withdrawal from benzodiazepines can lead to severe withdrawal symptoms, including seizures. Therefore, ensuring the safety of the client by initiating seizure precautions is the best initial nursing action.
Choice D rationale

While education is an important part of nursing care, in this situation, the client’s immediate physical needs take precedence.

A. Offer the client oral fluids B. Feed the client a snack C. Assess the breath sounds D. Empty the urinary drainage bag

Correct Answer is D

Explanation

Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.

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The nurse is reviewing laboratory results for a patient scheduled for a cholecystectomy. Which result is most important for the nurse to report to the surgeon?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

Correct Answer is C

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Correct Answer is D

Explanation

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