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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A) Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B) Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C) Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D) Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.

A. Drink between 8 to 10 cups (1.9 to 2.4 liters) of fluids daily. B. Choose complex carbohydrates that are high in fiber content. C. Eliminate the bedtime snack if heartburn develops after eating. D. Increase the percentage of protein in the diet if anemia develops. E. Avoid foods high in refined sugars.

Correct Answer is ["B","C","E"]

Explanation

A) Incorrect- While hydration is important, this response doesn't directly address the client's question about the content and timing of meals.
B) Correct- Complex carbohydrates high in fiber content have a slower impact on blood glucose levels, promoting better glycemic control.
C) Correct- Bedtime snacks can be helpful to prevent nighttime hypoglycemia, but if heartburn develops, it may be necessary to modify the timing or content of the snack.
D) Incorrect- This response is not directly related to managing blood glucose levels or gestational diabetes.
E) Correct- Refined sugars can cause rapid spikes in blood glucose levels, so avoiding them helps maintain stable glycemic control.

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Naxlex Comprehensive Predictor Exams

A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Patient Data Exhibits Which 3 responses should the diabetic nurse educator provide?

Correct Answer is ["B","C","E"]

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.

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

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) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)

When conducting diet teaching for a client who is on a postoperative full-liquid diet, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?