A client is transferred to the surgical intensive care unit after an exploratory laparotomy following a gunshot wound to the abdomen. The post anesthesia care unit (PACU) nurse reports to the receiving nurse the total amount of blood loss during surgery, intravenous catheter sites and fluid currently infusing. The PACU nurse also includes the time of the last administration of pain and nausea medications. Which additional information should the nurse provide to complete the report?

History of vomiting at home for 3 days prior to surgery.

Soft abdomen, absent bowel sounds, no bleeding on dressing.

Refuses to take ice chips for complaints of dry mouth.

Peripheral pulses present with full range of motion of both legs.

Answer and Explanation

The Correct Answer is B

Choice A rationale: While a history of vomiting at home for 3 days prior to surgery may be relevant, the information provided by the PACU nurse already includes the time of the last administration of nausea medications, making this option less critical at this moment.

Choice B rationale: Providing information about the abdomen, bowel sounds, and the absence of bleeding on the dressing is essential for assessing the postoperative condition of the client. It gives the receiving nurse a comprehensive overview of the client's immediate status following surgery.

Choice C rationale: Refusal to take ice chips for complaints of dry mouth is relevant to the client's comfort and hydration but may not be as critical as assessing surgical outcomes and complications.

Choice D rationale: Information about peripheral pulses and the range of motion of both legs is important but may be more pertinent to the neurological and circulatory assessment rather than immediate postoperative concerns. The surgical site and abdominal assessment are more directly related to the recent laparotomy.

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Correct Answer is A

Explanation

Choice A rationale: The immediate priority during a fire alarm is to ensure the safety of clients and staff. Instructing everyone to stay in the client rooms with doors closed helps contain any potential smoke or fire, providing protection while the situation is assessed.
Choice B rationale: Instructing family members to stay in the waiting area might not be the primary concern during a fire alarm. The focus is on the safety of clients and staff.
Choice C rationale: While determining the nature of the emergency is important, taking immediate actions to ensure safety is the priority. The charge nurse can address the cause once the safety of individuals is secured.
Choice D rationale: Evacuating clients should only be considered if it is determined to be safe to do so. It's crucial to assess the situation and follow established protocols before initiating evacuation.

A. Remind the UAP to apply a fitted respirator mask before entering the client's room. B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. C. Assign the UAP to provide care for another client and assume full care of the client. D. Review the need for the UAP to wear a face mask while in close contact with the client.

Correct Answer is D

Explanation

A. Remind the UAP to apply a fitted respirator mask before entering the client's room: A fitted respirator (N95 mask) is used for airborne precautions (e.g., tuberculosis), not droplet precautions like influenza.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: This is beyond the UAP’s scope of practice. Assessment and clinical judgment are the nurse’s responsibility.
C. Assign the UAP to provide care for another client and assume full care of the client: There is no indication that the UAP is incapable of providing care once properly instructed in precautions.
D. Review the need for the UAP to wear a face mask while in close contact with the client: Influenza is spread via respiratory droplets, so a surgical mask is required when within 3 feet of the client. This action ensures appropriate use of personal protective equipment (PPE).

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Naxlex Comprehensive Predictor Exams

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Correct Answer is A

Explanation

A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?

Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?

During a 24-hour electronic health record review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which immediate action is best for the nurse to take?

The nurse-manager overhears a nurse complaining to a co-worker about the time being required to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]