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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.

A. Reduce white blood cell count. B. Body temperature within normal limits. C. Decrease blood pressure. D. Negative urine culture. E. Incision free of exudate.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale: Reducing the white blood cell count is not a goal of SIRS treatment, as it would impair the immune system's ability to fight the infection.

Choice B rationale: Maintaining body temperature within normal limits is a collaborative goal to address the signs of SIRS.

Choice C rationale: Decreasing blood pressure is not typically a goal in the management of SIRS; the focus is on maintaining adequate perfusion.

Choice D rationale: Achieving a negative urine culture is a collaborative goal to address the underlying urinary tract infection.

Choice E rationale: incision free of exudate is an indicator of resolving infection and inflammation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?

Correct Answer is D

Explanation

The nurse is caring for an older adult who was admitted with a urinary tract infection and is now exhibiting signs of severe inflammatory response syndrome (SIRS). Which collaborative care goal(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?

An adult client is admitted via the emergency department (ED) with a head injury that will initially require intensive care. Which nurse should be responsible for coordinating the progression of this client's care through rehabilitation and discharge?

After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?

A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organizations budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

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?