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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
- The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
- The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
- The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
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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