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 C
Explanation
Choice A reason: Evaluating and updating plans of care for clients is not a task that can be delegated to a PN, as it requires nursing judgment and critical thinking. The nurse should perform this task and coordinate the care team.
Choice B reason: Completing comprehensive assessments is not a task that can be delegated to a PN, as it involves collecting and analyzing data from multiple sources. The nurse should perform this task and document the findings.
Choice C reason: Determining the need for urinary catheterizations is a task that can be delegated to a PN, as long as they have the necessary skills and knowledge. The PN should follow the established protocols and report any complications or changes to the nurse.
Choice D reason: Measuring preoperative clients for elastic stocking size is a task that can be delegated to a UAP, as long as they have been trained and supervised by the nurse. The UAP should follow the instructions and report any problems or concerns to the nurse.
Correct Answer is B
Explanation
Choice A reason: This is not a correct intervention because the nurse should respect the client's autonomy and confidentiality. The nurse should not disclose the client's diagnosis to the family without the client's consent.
Choice B reason: This is a correct intervention because the nurse should support the client's decision-making process and help the client explore the benefits and risks of informing or not informing the family. The nurse should also provide emotional support and counseling to the client.
Choice C reason: This is not a correct intervention because the nurse should not suggest genetic screening to the family without the client's permission. The nurse should also not imply that the client's condition is hereditary or that the family is at risk.
Choice D reason: This is not a correct intervention because the nurse should not notify the health department of the client's condition. The nurse should protect the client's privacy and follow the ethical and legal standards of nursing practice.
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