The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 x 103/μL;

hemoglobin 15 g/dL; hematocrit 45%; platelets 150 x 103/μL. Which action should the nurse

take?

Notify the surgeon and anesthesiologist immediately.

Ask the patient about any symptoms of a recent infection.

Continue to prepare the patient for the surgical procedure.

Answer and Explanation

The Correct Answer is C

C. The client’s laboratory values are all within normal range. It is therefore, safe for the nurse to proceed with preparation for theatre.

A. Notifying the provider immediately is a preferred action in the case of any abnormal laboratory values of concern.

B. Questioning on the recent infection would be relevant if the white blood count is elevated which is not the case in this scenario.

D. The client’s hemoglobin is within normal range and therefore, no need for transfusion at this point.

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Correct Answer is C

Explanation

C. The weights in skeletal traction should not rest against the foot of the bed. Placing the weights on the floor or using a weight-bearing device such as a frame or stand is necessary to provide countertraction and maintain proper tension on the traction system.

A. In skeletal traction, the ropes or cables should be securely attached to the pins that are inserted into the bone. Proper attachment ensures that the traction force is applied effectively and safely.

B. In balanced skeletal traction, the weights on each side of the traction setup should be equal to maintain proper alignment and traction force. Balanced traction helps prevent unequal forces on the bone and surrounding tissues.

D. The ropes or cables should be properly positioned in the center of the wheel grooves to ensure smooth movement of the weights and prevent binding or friction. Proper alignment of the ropes reduces the risk of malfunction or damage to the traction equipment.

A. Continue to take vital signs every 15 minutes. B. Notify the anesthesia care provider (ACP). C. Increase the postoperative IV fluid rate. D. Administer oxygen therapy at 100% per mask.

Correct Answer is A

Explanation

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

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The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 x 103/μL;

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

Correct Answer is C

Explanation

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Correct Answer is A

Explanation

The nurse is caring for a patient who has diabetes and reports chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain?

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?

A post-operative patient is scheduled for ambulation. Which of the following patients should be prioritized for ambulation?

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)