markwarrick - Tumblr blog

markwarrick · 4 years

Text

1. The nurse is performing presurgical assessment of multiple clients. The nurse determines that which client has the greatest risk for developing an infection postoperatively?

The client with new-onset neutropenia of unknown etiology

The client with thrombocytopenia secondary to taking aspirin

The child newly diagnosed with type 1 diabetes mellitus (DM)

The client who needs assistance with ambulation due to arthritis

ANSWER: A

Neutropenia is a reduction in neutrophils, the body’s first line of defense in phagocytosis of invading microorganisms. Neutropenia predis- poses the client to infection with nonpathogenic organisms that are present in normal body flora as well as opportunistic pathogens.

Thrombocytopenia is a reduction in platelets. Thrombocytopenia predisposes the client to bleeding.

The client with DM is more susceptible to infections because there is a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes. Although at risk, the client with neutropenia has a greater risk.

If assistance is provided for activity, there should not be an increased risk.

2. The client being admitted for same-day surgery has inspiratory crackles and bilateral wheezes, and reports shortness of breath for several days. Which intervention should the nurse implement first?

Notify the surgeon of the findings.

Document the assessment findings.

Apply 4 liters oxygen by nasal cannula.

Instruct on using an incentive spirometer (IS).

ANSWER: A

The nurse should notify the surgeon of unanticipated changes in the health status of the preoperative client. Surgery may need to be postponed.

The nurse should first notify the surgeon and then document the findings and the notification.

There are no objective data supporting the need for oxygen.

Although an IS may be prescribed, notifying the surgeon is the priority.

#nclexrn #nclexstudying #nclex #nclex exam

0 notes