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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The client with a kidney transplant experiencing "flu-like" symptoms can be evaluated for urgency but may not require the first available appointment.
Choice B rationale: The client with non-radiating, low-back pain rated at 10 on a scale of 0 to 10 should be assessed, but it may not be an immediate concern compared to the other options.
Choice C rationale: The client at 3-weeks gestation with a small amount of bright red blood after passing stool requires evaluation, but it may not be as urgent as the client in Choice D.
Choice D rationale: The 2-year-old girl with a history of a "cold," tugging on her ear, and a fever of 102 F (38.9° C) may have an ear infection, which could be an acute problem requiring prompt evaluation.
Correct Answer is A
Explanation
Choice A rationale: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee can help the orientee improve her skills and confidence.
Choice B rationale: Waiting until the end of the second week may lead to further issues and does not actively address the current challenges the orientee is facing.
Choice C rationale: Informing the supervisor without directly addressing the nurse may not be the most supportive or proactive approach.
Choice D rationale: Talking to the orientee about working in a less stressful environment may not be the most proactive step at this point. Providing support and guidance within the current work environment is a more immediate solution.
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