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 B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

A. Low-fat dairy products. B. Fresh fruits and vegetables. C. Iron-rich meals. D. Water and herbal teas.

Correct Answer is A

Explanation

A: Dairy products such as milk, yogurt, and cheese are rich sources of calcium, which is essential for bone health and can help prevent osteoporosis, especially in older adults.
B: While fruits and vegetables are important for overall health, they do not provide significant amounts of calcium, which is the primary nutrient needed for preventing osteoporosis.
C: Iron-rich meals are important for preventing anemia but do not directly contribute to bone health and prevention of osteoporosis.
D: While hydration is important for overall health, water and herbal teas do not provide significant amounts of calcium needed for bone health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is A

Explanation

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

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

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

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