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. Offering 10% dextrose via nipple feeding is used for infants who are unable to feed orally or with severe hypoglycemia. This neonate is still within range hence dextrose is not incicated at this point.

B. The infant is jittery with a glucose of 40 mg/dL, which indicates mild symptomatic hypoglycemia. Initiating frequent feedings of breast milk or formula is the first action to stabilize glucose while supporting oral intake.
C. Repeating the heel stick is important for monitoring, but it does not treat the low glucose and is not the first action.
D. Assessing for hypocalcemia may be indicated later, but the priority is addressing hypoglycemia through feeding.

A. Administer a prescribed narcotic antagonist to reverse the eﬀects of any analgesic accumulation. B. Notify the healthcare provider and request a prescription for restraints to minimize the client's danger to self. C. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. D. Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.

Correct Answer is C

Explanation

The client may be experiencing postoperative delirium, which is a transient state of confusion, disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients. The PN should raise the side rails and notify the family to come and stay with the client, as this can provide safety, comfort, and reassurance for the client.

The other options are not correct because:

A. Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.

B. Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.

D. Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or eﬀective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

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?

An older adult female asks the practical nurse (PN) if she should get a Herpes zoster (shingles) vaccination because she gets cold sores on her mouth when she is sick or stressed. Which response should the PN provide?

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

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.

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?

While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?