The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy.
The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining.
Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea.
The last dose was administered at 0700.
The client is currently describing pain at a level 2 on a 0 to 10 pain scale.
The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain.
The last dose was administered at 1000." Which additional information should the PACU nurse report?
History of vomiting at home for 3 days prior to surgery.
Soft abdomen, absent bowel sounds, no bleeding on dressing.
Declining to take ice chips for complaints of dry mouth.
Peripheral pulses present with full range of motion of both legs.
The Correct Answer is A
Choice A rationale:
History of vomiting at home for 3 days prior to surgery. Rationale: This information is relevant to the client's surgical history and may impact their current condition. It is essential to inform the receiving nurse about this history to ensure appropriate postoperative care.
Choice B rationale:
Soft abdomen, absent bowel sounds, no bleeding on dressing. Rationale: While this information is important for assessing the client's postoperative status, it is less urgent than the history of vomiting. The abdominal assessment suggests normal findings after surgery.
Choice C rationale:
Declining to take ice chips for complaints of dry mouth. Rationale: While this information indicates the client's complaint of dry mouth, it is not as critical as the history of vomiting or the assessment of surgical outcomes.
Choice D rationale:
Peripheral pulses present with full range of motion of both legs. Rationale: This information is important but primarily related to the client's vascular and neurological status. It may not be as immediately relevant as the history of vomiting in the context of a recent surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.
Choice B rationale:
This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.
Choice C rationale:
Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.
Choice D rationale:
Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.
Choice B rationale:
This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.
Choice C rationale:
This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.
Choice D rationale:
This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.
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