While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.
Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?
Hematocrit.
Neutrophil count.
Platelet count.
Serum sodium level.
The Correct Answer is B
Choice A rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
Choice B rationale
Neutrophil count is a measure of the number of neutrophils, a type of white blood cell, in the blood. An elevated neutrophil count can indicate an infection, making it the most relevant lab value to check in this scenario.
Choice C rationale
Platelet count is a measure of the number of platelets in the blood. While platelets play a crucial role in blood clotting, they are not directly related to infection and therefore not the most relevant lab value to check in this scenario.
Choice D rationale
Serum sodium level is a measure of the amount of sodium in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.
Choice B rationale
Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.
Choice C rationale
Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.
Choice D rationale
Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.
Correct Answer is ["A","C","E"]
Explanation
- A. Set up supplemental oxygen delivery- This could be necessary as the client is being weaned off the ventilator and may require additional oxygen support.
- C. Gather supplies for extubation- As the client is being weaned off the ventilator and the pressure support has been decreased to 0 cm H2O, extubation may be imminent.
- E. Offer the client ice chips- Once extubated, the client may have a dry mouth and throat from the intubation tube. Ice chips can help soothe the throat and keep the mouth moist.
- B. Increase the fraction of inspired oxygen- This action is not indicated based on the information provided. The client’s oxygen saturation is within normal range and there’s no indication that the client is experiencing difficulty breathing or hypoxia.
- D. Place a nasogastric tube- There’s no indication in the scenario that the client has a need for a nasogastric tube. This procedure is typically done for clients who have difficulty swallowing or need help with feeding, neither of which is mentioned in the scenario.
- F. Suggest a different ventilator mode to the provider- The client is already being successfully weaned off the ventilator, as indicated by the decreasing pressure support. There’s no indication in the scenario that a different ventilator mode is needed.
- G. Set the ventilator to give mandatory breaths- This action would be counterproductive to the weaning process. The client is already on a ventilator mode with no mandatory breaths and is being successfully weaned off the ventilator.
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