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 D

Explanation

Choice A rationale: Directing the UAP to delay weighing the client might not address the underlying issue. Understanding the client's refusal is essential for appropriate interventions.

Choice B rationale: Documenting that the client refused daily weights is important for documentation purposes, but it doesn't address the issue or provide information on the client's fluid status.

Choice C rationale: Instructing the UAP to weigh the client using a bed scale is a good option, but understanding the client's concerns or reasons for refusal is important for effective communication and addressing potential issues.

Choice D rationale: Asking the client why he does not want to be weighed is essential for understanding and addressing the client's concerns. It allows the nurse to provide education, reassurance, or alternative solutions to ensure the client's cooperation with the prescribed care plan.

A. Managed healthcare plans do not pay for any in-hospital medical evaluations. B. The client is grieving normally in response to the loss of a spouse and hospitalization is not necessary. C. Managed care providers have mandatory precertification requirements for hospitalization. D. Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital.

Correct Answer is C

Explanation

Choice A rationale: This statement is inaccurate. Managed healthcare plans typically cover in-hospital medical evaluations, but the decision may be subject to precertification requirements.

Choice B rationale: While grief is a natural response to the loss of a spouse, the client's confusion and disorientation warrant a medical evaluation, and this option dismisses the family's concerns.

Choice C rationale: Managed care providers often have mandatory precertification requirements for hospitalization. Informing the family about this requirement is important for them to navigate the process effectively.

Choice D rationale: This statement does not provide relevant information about the managed healthcare plan's policies or the client's current condition.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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?

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?

The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medications administered during the evening shift on a postsurgical unit is higher than usual. Which action should the nurse manager take first?

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?

Aspirin 81 mg at 0900 daily is prescribed for an adult client. At 0800 the client asks for something for low back pain, but does not have any PRN analgesics prescribed. Which action is best for the nurse to take?

A client is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and reports that it is difficult to eat due to shortness of breath (SOB). Which task(s) should the nurse delegate to the unlicensed assistant personnel (UAP)? Select all that apply.

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?