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 B
Explanation
Choice A rationale: Waiting until 0830 and administering the aspirin would not address the client's immediate need for pain relief.
Choice B rationale: Obtaining a prescription for a PRN analgesic is the most appropriate action to provide the client with effective pain relief.
Choice C rationale: Assessing the client's prothrombin time (PT)/international normalized ratio (INR) is not necessary in this context and does not address the immediate pain concern.
Choice D rationale: Administering the prescribed daily aspirin now would not address the client’s lower back pain at the moment.
Correct Answer is D
Explanation
Choice A rationale: Instructing unlicensed assisted personnel to transfer non-ambulatory clients via wheelchairs may delay the evacuation process and put clients at risk. Choice B rationale: Announcing that visitors should proceed immediately to the first floor via the service elevators may cause congestion and hinder the evacuation of clients.
Choice C rationale: Shutting all doors to client rooms and telling everyone to stay in their rooms is not a safe strategy during a fire evacuation. It may increase the risk of harm to clients and staff.
Choice D rationale: Instructing the nursing staff to evacuate ambulatory clients to the nearest fire exits is the most appropriate and timely action to ensure the safety of both clients and staff during a fire evacuation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.