An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?
Police department wants to be notified when the client is alert.
Neurovascular assessments below the fracture are normal.
No nausea or vomiting during the PACU recovery stay.
The family is requesting a private room when one is available.
The Correct Answer is B
Choice A reason: This is not a relevant information to complete the report. The police department may want to interview the client about the MVC, but this is not a priority for the nurse or the healthcare provider.
Choice B reason: This is a relevant information to complete the report. The neurovascular assessments below the fracture are important to monitor the blood flow and nerve function of the affected limb. Normal findings indicate that the fracture and the surgery did not cause any complications or impairments.
Choice C reason: This is not a relevant information to complete the report. The absence of nausea or vomiting during the PACU recovery stay is a positive outcome, but it does not affect the current pain management or the postoperative care of the client.
Choice D reason: This is not a relevant information to complete the report. The family's request for a private room is a matter of preference and availability, but it does not influence the clinical status or the treatment plan of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Discussing why visitors should not lie in the bed with the client is not the best action for the nurse to implement. The nurse should not waste time explaining the rationale to the visitor, as this may cause conflict or resentment. The nurse should focus on the immediate safety and comfort of the client and the visitor.
Choice B reason: Notifying the charge nurse that the visitor is lying on the client's bed is not the best action for the nurse to implement. The nurse should not escalate the situation to the charge nurse, as this may imply that the nurse is unable to handle the problem. The nurse should use his or her own authority and judgment to resolve the issue.
Choice C reason: Explaining that the client has the right to have a visitor lie on the bed is not the best action for the nurse to implement. The nurse should not condone or encourage the visitor's behavior, as this may compromise the client's health and hygiene. The nurse should respect the client's wishes, but also uphold the standards of care and infection control.
Choice D reason: Instructing the UAP to ask the visitor to get off the client's bed is the best action for the nurse to implement. The nurse should delegate the task to the UAP, who has already established rapport with the visitor and the client. The nurse should also monitor the situation and ensure that the UAP is polite and respectful to the visitor and the client.
Correct Answer is B
Explanation
Choice A reason: This is not a relevant information to complete the report. The police department may want to interview the client about the MVC, but this is not a priority for the nurse or the healthcare provider.
Choice B reason: This is a relevant information to complete the report. The neurovascular assessments below the fracture are important to monitor the blood flow and nerve function of the affected limb. Normal findings indicate that the fracture and the surgery did not cause any complications or impairments.
Choice C reason: This is not a relevant information to complete the report. The absence of nausea or vomiting during the PACU recovery stay is a positive outcome, but it does not affect the current pain management or the postoperative care of the client.
Choice D reason: This is not a relevant information to complete the report. The family's request for a private room is a matter of preference and availability, but it does not influence the clinical status or the treatment plan of the client.
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