While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

Culture and sensitivity

C-reactive protein level

Serum blood glucose level

Blood pH level

Answer and Explanation

The Correct Answer is A

Choice A reason: Culture and sensitivity identify the causative organism and antibiotic susceptibility of purulent drainage, indicating a wound infection. This guides targeted antimicrobial therapy, as postoperative infections may involve resistant bacteria like MRSA, ensuring effective treatment and preventing complications like sepsis or delayed healing.

Choice B reason: C-reactive protein indicates systemic inflammation but is non-specific for wound infections. Purulent drainage requires pathogen identification via culture to guide therapy. While elevated CRP may support infection suspicion, it does not direct antibiotic choice, making it less critical than culture results.

Choice C reason: Serum blood glucose is relevant for wound healing, as hyperglycemia impairs immune response, but it does not identify the infection’s cause. Purulent drainage requires microbiological data from culture to select antibiotics, making glucose levels secondary for immediate infection management.

Choice D reason: Blood pH level assesses acid-base balance, irrelevant to localized wound infection. Purulent drainage indicates bacterial infection, requiring culture to identify pathogens. pH may be altered in systemic sepsis, but culture is the priority for guiding therapy in postoperative wound infections.

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Correct Answer is C

Explanation

Choice A reason: Monitoring urine output assesses fluid status but does not directly prevent hypernatremia, which results from excess sodium or water loss. Reducing dietary sodium intake is more proactive, as urine output is a secondary indicator, making this instruction less effective for management.

Choice B reason: Using salt tablets after exercise is dangerous, as they increase sodium intake, worsening hypernatremia. This condition requires sodium reduction and water replacement, making this instruction harmful, as it exacerbates elevated serum sodium levels, risking neurological complications.

Choice C reason: Reviewing food labels for sodium content is critical, as hypernatremia results from high sodium intake or water loss. Limiting dietary sodium prevents further elevation of serum sodium, protecting against cerebral edema or seizures, making this the most effective discharge instruction.

Choice D reason: Drinking water when thirsty helps hydration but is reactive and insufficient for hypernatremia, which requires proactive sodium reduction. Thirst may be impaired in some patients, and dietary sodium control is more direct, making this instruction less comprehensive than label review.

A. Reports of chronic constipation and serum gastrin levels B. Presence of bowel sounds and degree of abdominal pain C. Severity of nausea and vomiting and serum amylase results D. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts

Correct Answer is C

Explanation

Choice A reason: Chronic constipation and gastrin levels are irrelevant to pancreatitis. Gastrin relates to gastric acid production, not pancreatic inflammation. Pancreatitis is confirmed by amylase/lipase elevation, and constipation does not reflect its severity, making this information less valuable for reporting.

Choice B reason: Bowel sounds and abdominal pain degree provide general data but are non-specific. Pancreatitis requires amylase/lipase levels for diagnosis, and nausea/vomiting severity better indicates clinical status, making this information secondary to laboratory confirmation and symptom severity.

Choice C reason: Severity of nausea and vomiting and serum amylase results are critical, as elevated amylase confirms pancreatitis, and nausea/vomiting severity reflects disease impact. These directly inform the provider about pancreatic inflammation and clinical status, making this the most valuable information to report.

Choice D reason: H. pylori antibodies and urine output are unrelated to pancreatitis. H. pylori causes gastritis, and urine output monitors hydration, but amylase and nausea/vomiting directly address pancreatitis’s diagnosis and severity, making this information less relevant for immediate reporting.

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While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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