The nurse of a medical-surgical unit receives a report from a postanesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an IV infusion of 1,000 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?
Peripheral pulses present with full range of motion of both legs.
History of vomiting at home for 3 days prior to surgery.
Troubled by a dry mouth but refuses to take ice chips.
Soft abdomen, absent bowel sounds, no bleeding on dressing.
The Correct Answer is D
A. While it's important to know about peripheral pulses and mobility, this is not as critical immediately post-op.
B. A history of vomiting is relevant but not immediately actionable for the current post-op care.
C. Dry mouth is a common and manageable symptom post-op, but not immediately critical.
D. A soft abdomen, absent bowel sounds, and no bleeding on dressing provide essential information on the client's current post-op status and potential complications, making it the most important information to confirm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While physical activity is important for overall health, it may not directly address constipation. Increasing fluid and fiber intake is a more specific intervention.
B. Stool softeners can be helpful, but dietary modifications should be attempted first before resorting to medications.
C. Gas-producing foods may not be directly related to constipation. The focus should be on promoting regular bowel movements through diet and hydration.
D. Increasing fluid and fiber intake is a recommended first-line approach for managing constipation in older adults.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
1. Working with an addiction therapist for several months will assist in my recovery. This statement reflects an acknowledgment of the importance of therapy in her recovery process, indicating an understanding of the treatment plan.
2. The Alcoholics Anonymous program would be a great resource, but they do not have meetings when I'm free.
While it acknowledges AA as a resource, it doesn't show an understanding of prioritizing meetings or seeking alternative solutions.
3. It is not safe for me to drink alcohol, but I am still able to smoke marijuana without problems.
This indicates a misconception; if alcohol is unsafe, other substances likely are too.
4. Identifying potential triggers allows me to proactively utilize coping strategies.
This statement demonstrates an understanding of the importance of identifying triggers and implementing coping strategies to prevent relapse, indicating engagement in the treatment process.
5. Relapse is an expected complication of substance use; thus, prevention strategies and awareness of my emotions are important.
Acknowledging relapse as a potential complication and recognizing the importance of prevention strategies and emotional awareness indicates a realistic understanding of the challenges associated with recovery.
6. The treatment options for alcoholism are limited to inpatients, with very few resources for outpatients.
This is factually incorrect and doesn't show understanding of the variety of treatment options available.
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