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 B
Explanation
A. Providing condoms in health clinics is a preventive measure but does not directly indicate the effectiveness of the secondary prevention program.
B. Diagnosing at-risk clients early in the disease process indicates successful secondary prevention efforts, as early diagnosis allows for prompt treatment and prevention of further transmission.
C. While increasing HPV vaccine prescriptions is a positive outcome, it does not directly reflect the effectiveness of the program in preventing STIs.
D. Improved client knowledge is important but does not directly measure the program's effectiveness in preventing STIs.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.
Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.
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