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.

Nursing Test Bank

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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.

A. A client who has protein calorie malnutrition B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has right-sided heart failure and 4+ edema to the lower extremities D. A client who has postoperative delirium E. A client who is ambulatory following a cardiac catheterization 4 hr ago

Correct Answer is ["A"]

Explanation

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

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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 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

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Correct Answer is ["A"]

Explanation

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