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: This is not a correct assignment because the PN cannot obtain a report on a client with unstable angina, which is a complex and potentially life-threatening condition that requires the RN's assessment and intervention.
Choice B reason: This is not a correct assignment because the UAP cannot assist with the thoracentesis, which is an invasive and high-risk procedure that requires the RN's or the healthcare provider's skills and knowledge.
Choice C reason: This is not a correct assignment because the RN should not leave the unit to obtain report on a new admission while a thoracentesis is being performed. The RN should be available to monitor the client's vital signs, oxygen saturation, and potential complications during and after the procedure.
Choice D reason: This is a correct assignment because the PN can go to the ED to obtain report and transport the client with unstable angina, which is within the PN's scope of practice. The UAP can prepare the room for the new admission, which is a simple and routine task. The RN can assist with the thoracentesis, which is an advanced and critical skill.
Correct Answer is C
Explanation
Choice A reason: Calling the client's next of kin and having them provide verbal consent is not the appropriate action for the nurse to take. The client is an adult and has the right to make his own decisions about his health care. The nurse should respect the client's autonomy and not involve his family without his permission.
Choice B reason: The nurse can reinforce information but cannot provide the primary explanation of the procedure. The HCP must clarify any confusion before consent is valid.
Choice C reason: Informed consent requires that the client fully understands the procedure, risks, benefits, and alternatives before signing. The healthcare provider (HCP) is responsible for explaining the procedure, not the nurse. Since the client’s question indicates misunderstanding, the nurse must notify the provider so they can clarify the information before consent is obtained.
Choice D reason: Postponing the procedure until the client understands the risks/benefits is not the best action for the nurse to take. The cardiac catheterization may be a time-sensitive and necessary procedure for the client's condition. The nurse should not delay the procedure without a valid reason. The nurse should try to enhance the client's understanding and confidence before postponing the procedure.
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