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","D"]

Explanation

A) Incorrect - Providing a regular diet tray is important for the client's nutritional needs, but it is not as urgent as assessing vital signs or administering Albuterol in response to the client's acute symptoms.
B) Correct- This action is a priority after any assessment or intervention. Vital signs provide important information about the client's overall condition, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
C) Incorrect - Applying oxygen is important, but its priority depends on the client's vital signs and oxygen saturation, which should be assessed first.
D) Correct- Administering Albuterol as ordered is crucial for addressing the client's acute breathing difficulty. Albuterol is a bronchodilator that helps alleviate asthma symptoms, and timely administration is essential.
E) Incorrect - Performing a pulmonary function test is valuable for assessing lung function, but it's not an immediate concern compared to addressing the client's breathing difficulty.

A. Explains the examination and asks the client to sign the consent form. B. Checks the medical record for the correct signed consent form prior to the examination. C. Explains to a family member and obtains their signature on the consent form. D. Asks if the client understands the exam and why the consent form must be signed. E. None F. None

Correct Answer is B

Explanation

A. Explaining the examination and asking the client to sign the consent form is not within the PN's scope of practice. It is the responsibility of the healthcare provider performing the procedure to explain the risks, benefits, and alternatives of the exam and to obtain informed consent from the client.

B. Checking the medical record for the correct signed consent form prior to the examination is an essential role for the practical nurse. It ensures that informed consent has been obtained and documented before proceeding with any invasive procedure, aligning with the PN's responsibility to verify necessary documentation.

C. Explaining to a family member and obtaining their signature on the consent form may be appropriate only if the client is unable to provide consent and has a legal representative. However, obtaining consent and explaining the procedure is still the responsibility of the healthcare provider, not the PN.

D. Asking if the client understands the exam and why the consent form must be signed is part of the PN's role in ensuring that the client is informed, but the PN cannot assume responsibility for explaining the procedure in detail. This should be done by the healthcare provider who will perform the exam.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

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

Explanation

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)?

Correct Answer is B

Explanation

A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication?

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (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.)

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

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

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?