The Operating Room (OR) nurse is preparing to give report to the Intensive Care Unit (ICU) nurse on a patient who has had surgery after suffering penetrating chest and abdominal trauma. What should the nurse include in the report? (Select All that Apply.)

Description of injury, vital signs during surgery, and current vital signs

Description of operative procedure and patient tolerance

Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss)

Presence of the patients spiritual advisor and family

Medications administered during surgery and IV access sites

Answer and Explanation

Correct Answer : A,B,C,E

A) Description of injury, vital signs during surgery, and current vital signs:
This information is crucial for the ICU nurse to understand the nature of the injury, how the patient responded during surgery, and their current hemodynamic status. Vital signs during surgery provide insight into the patient's cardiovascular stability and response to anesthesia, blood loss, and interventions. Current vital signs are important to monitor for any postoperative complications.

B) Description of operative procedure and patient tolerance:
The ICU nurse needs to know the details of the surgery performed, such as the type of trauma repair and any complications that may have occurred during the procedure. Understanding how the patient tolerated the surgery (e.g., any complications such as hypotension or arrhythmias) is important for planning post-operative care and anticipating potential issues in the ICU.

C) Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss):
Tracking fluid balance is critical in trauma patients, especially those who have suffered significant blood loss. IV fluids, blood products, and other inputs (such as urine and chest tube output) provide vital information on the patient's circulatory status and renal function. Blood loss is also important to monitor, as it may need to be replaced, and fluid status affects the patient's recovery.

D) Presence of the patient's spiritual advisor and family:
Although family presence can be an important part of patient care, especially in a trauma situation, it is not essential information for the ICU nurse to receive during a report. While the ICU nurse may ask for family updates and visitor information, the focus of the report should be on the patient's clinical status and post-operative needs.

E) Medications administered during surgery and IV access sites:
The ICU nurse must know the medications administered during surgery, especially anesthesia agents, antibiotics, and analgesics, to understand their effects and anticipate any needed follow-up care, such as pain management or monitoring for adverse reactions. Knowing the IV access sites (e.g., central line, peripheral IV) is important for administering medications, fluids, and for monitoring potential complications related to vascular access.

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Correct Answer is A

Explanation

A) Provide honest answers to the client’s questions:
Providing honest answers to the client's questions is essential in promoting comfort, especially when they have a new diagnosis of bladder cancer. Patients often experience anxiety and uncertainty when facing a new diagnosis, so being open and transparent with information can help alleviate fears and build trust.

B) Avoid eye contact with the client during care:
Avoiding eye contact with the client can contribute to feelings of isolation and discomfort. Eye contact is an important form of non-verbal communication that can help establish a rapport and show empathy. Avoiding eye contact could make the client feel rejected or neglected, which would increase their anxiety and distress.

C) Provide limited explanations of procedures needed for care:
Providing limited explanations of procedures may leave the client feeling more confused or fearful about what is happening. While it's important to avoid overwhelming the patient with too much information, clear and concise explanations about procedures and treatments are essential to reduce anxiety and help the patient feel more in control of the situation.

D) Avoid giving the client choices regarding their care:
Avoiding giving the patient choices can make them feel powerless, which can increase feelings of anxiety and frustration. Offering choices when appropriate allows the patient to feel more in control of their care, which can reduce stress and enhance their sense of autonomy.

A. Ascites B. Alopecia C. Generalized edema D. Petechiae E. Epistaxis

Correct Answer is ["D","E"]

Explanation

A) Ascites
Ascites, the accumulation of fluid in the peritoneal cavity, is not a typical initial assessment finding in acute lymphocytic leukemia (ALL). While ascites can occur in some cancers or in cases of liver failure, it is not a hallmark or common finding in ALL. The focus in ALL would generally be on hematologic and immunologic symptoms rather than fluid accumulation in the abdomen.

B) Alopecia
Alopecia (hair loss) is more commonly associated with chemotherapy treatment for leukemia rather than the leukemia itself. While chemotherapy for ALL can lead to hair loss, it is not typically an initial symptom of the disease itself. Alopecia may appear later, as a side effect of cancer treatment.

C) Generalized edema
Generalized edema (swelling) is not a common or early sign of acute lymphocytic leukemia. While edema can occur in certain malignancies or complications (like in cases of renal failure or heart failure), it is not typically an initial presenting symptom of ALL. The key manifestations of ALL tend to relate to hematologic abnormalities, rather than fluid accumulation.

D) Petechiae
Petechiae (small, red or purple spots on the skin) are a common finding in ALL. They occur due to thrombocytopenia (low platelet count), which is a hallmark of leukemia. Thrombocytopenia impairs the blood’s ability to clot, leading to bleeding under the skin. Petechiae is often one of the first visible signs of blood dyscrasia in leukemia patients.

E) Epistaxis
Epistaxis (nosebleeds) is another common initial finding in ALL. Like petechiae, epistaxis occurs due to thrombocytopenia, which impairs normal clotting and leads to spontaneous bleeding. Nosebleeds are frequently observed in patients with low platelet counts, especially in leukemia.

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The Operating Room (OR) nurse is preparing to give report to the Intensive Care Unit (ICU) nurse on a patient who has had surgery after suffering penetrating chest and abdominal trauma. What should the nurse include in the report? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of bladder cancer Which of the following interventions should the nurse take to promote comfort?

Correct Answer is A

Explanation

Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (SELECT ALL THAT APPLY)

Correct Answer is ["D","E"]

Explanation

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