The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 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?

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

Declining to take ice chips for complaints of dry mouth.

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

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

Answer and Explanation

The Correct Answer is D

A)   Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B)   Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C)   Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D)   Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

b. Begin frequent feedings of breast milk or formula.

The infant has hypoglycemia, which is a low blood glucose level that can cause jiteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

The other options are not correct because:

a. Oﬀering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

c. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

d. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jiteriness.

A. Instruct the mother to play with the child for stimulation and distraction B. Administer a dose of acetaminophen as needed C. Monitor the child's oxygen saturation level via pulse oximetry. D. Encourage the child to drink adequate amounts of ﬂuids

Correct Answer is C

Explanation

Croup is a respiratory infection that causes inﬂammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Correct Answer is C

Explanation

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

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

Patient Data Exhibits Which are the nurse's best responses? Select all that apply.

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?