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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Peanut butter sandwich with soda and cookies is not a high-protein choice and contains excessive sugar and empty calories.
B. Salad with lettuce and fruit may not provide sufficient protein for wound healing.

C. A tuna fish sandwich is high in protein, which aligns with the goal of promoting wound healing.
D. Vegetable soup, crackers, and milk lack adequate protein content compared to a tuna fish sandwich.

A. Bring a sterile chest drainage unit from central supply to the unit. B. Call the pharmacy to obtain a client's next antibiotic dose. C. Observe a client's gait to determine the need for assistance. D. Evaluate a client's urinary catheter for proper drainage.

Correct Answer is A

Explanation

A. Bringing a sterile chest drainage unit from central supply is a task that does not require clinical judgment and is suitable for a UAP.
B. Calling the pharmacy involves understanding and communication about medications, which should be handled by licensed staff.
C. Observing a client's gait to determine the need for assistance involves assessment and clinical judgment, which is beyond the UAP's scope.

D. Evaluating a client's urinary catheter for proper drainage requires assessment skills that are within the scope of licensed nurses.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

Correct Answer is C

Explanation

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of as evidenced by. neurological defects as evidenced by

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?