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.

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Correct Answer is A

Explanation

This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.

The other options are not correct because:

B . This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.

C. This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.

D. This statement indicates that the client is in the stage of blame, as he implies that his condition could have been prevented or treated if the doctor had diagnosed it earlier.

A. Skipped eating lunch. B. Incorrectly administered too much insulin. C. Had a cold and ear infection for the past two days. D. Ate an extra peanut butter sandwich before gym class. E. None F. None

Correct Answer is C

Explanation

A. Skipped eating lunch would more likely cause hypoglycemia rather than diabetic ketoacidosis (DKA). When a person with type 1 diabetes skips a meal but still takes insulin, blood glucose levels drop, leading to hypoglycemia, not the elevated glucose and ketone production seen in DKA.

B. Incorrectly administered too much insulin would also result in hypoglycemia rather than DKA. Administering excessive insulin causes blood glucose levels to fall too low, which does not trigger the fat breakdown and ketone production that characterize DKA.

C. Had a cold and ear infection for the past two days is the most likely cause of diabetic ketoacidosis. Illness and infection cause the body to release stress hormones such as cortisol and adrenaline, which increase blood glucose levels and counteract insulin. In type 1 diabetes, insufficient insulin leads to hyperglycemia, fat breakdown for energy, and the production of ketones, resulting in DKA.

D. Ate an extra peanut butter sandwich before gym class would not cause DKA. Consuming extra food may raise blood glucose temporarily, but it would not lead to the severe insulin deficiency and ketone production seen in DKA, especially if the adolescent took insulin as prescribed.

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Naxlex Comprehensive Predictor Exams

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

Correct Answer is A

Explanation

An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

Correct Answer is C

Explanation

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

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

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. Which action should the nurse take?

The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

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

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?