The nurse of a medical-surgical unit receives a report from a postanesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an IV infusion of 1,000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 mL remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8 hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report?

Peripheral pulses present with full range of motion of both legs.

History of vomiting at home for 3 days prior to surgery.

Troubled by a dry mouth but refuses to take ice chips.

Soft abdomen, absent bowel sounds, no bleeding on dressing.

Answer and Explanation

The Correct Answer is D

A.   While it's important to know about peripheral pulses and mobility, this is not as critical immediately post-op.
B.   A history of vomiting is relevant but not immediately actionable for the current post-op care.
C.   Dry mouth is a common and manageable symptom post-op, but not immediately critical.
D.   A soft abdomen, absent bowel sounds, and no bleeding on dressing provide essential information on the client's current post-op status and potential complications, making it the most important information to confirm.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A.Beginning with less sensitive questions helps establish trust and rapport with the client, making it easier to discuss more difficult topics later. This approach can make the client feel more comfortable and less threatened, thereby improving the quality of the information gathered.

B.Sharing personal values can introduce bias and potentially influence the client's responses, making the interview less objective.

C.Starting with the most difficult questions can make the client feel anxious and defensive, reducing the likelihood of obtaining honest and thorough responses.

D.Asking vague, non-specific questions can lead to ambiguous answers and fail to provide the detailed information needed for a proper assessment.

A. Determine apical pulse rate and rhythm. B. Observe color and amount of urine. C. Assess strength of deep tendon reflexes. D. Compare muscle strength bilaterally

Correct Answer is A

Explanation

A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the best approach for the nurse to use when interviewing a client about sexual abuse?

Correct Answer is A

Explanation

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Correct Answer is A

Explanation

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and orders. Drag from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developingdue to

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

Which is the priority nursing problem for a client with hypoparathyroidism?

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

A client receives a prescription for acetaminophen 1,000 mg PO every 8 hours PRN for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)