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. Ensuring comfort during the dying process is paramount in end-of-life care. Assessing and managing pain promptly supports quality of life and dignity in the client's final moments.
B. The nurse manager should be updated on the client's status. While communication with the nurse manager is important, it is not the immediate priority when a client is experiencing discomfort or pain.
C. The client's status should be conveyed to the chaplain. Involving spiritual care is important but secondary to addressing any immediate physical comfort needs of the client.
D. The impending signs of death should be documented. Documentation is important, but it is a secondary priority to the direct care and comfort needs of the client.

A. Oxygen saturation 98% on room air B. Urine output 20 mL in the last hour C. Basilar crackles D. Heart rate 72 beats/minute E. Respiratory rate 26 breaths/minute F. Blood pressure 126/76 mm Hg G. Electrocardiogram Tall T wave and widened QRS complex H. Temperature 98.9° F (37.1° C) orally

Correct Answer is ["A","D","E","F","H"]

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

Correct Answer is ["A","D","E","F","H"]

Explanation

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.2 mmol/L) about preventing complications related to diabetes mellitus. Which statement by the client indicates understanding? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choice(s) included on the client's list should the nurse encourage? Select all that apply.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?