The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy.
The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining.
Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea.
The last dose was administered at 0700.
The client is currently describing pain at a level 2 on a 0 to 10 pain scale.
The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain.
The last dose was administered at 1000." Which additional information should the PACU nurse report?
History of vomiting at home for 3 days prior to surgery.
Soft abdomen, absent bowel sounds, no bleeding on dressing.
Declining to take ice chips for complaints of dry mouth.
Peripheral pulses present with full range of motion of both legs.
The Correct Answer is A
Choice A rationale:
History of vomiting at home for 3 days prior to surgery. Rationale: This information is relevant to the client's surgical history and may impact their current condition. It is essential to inform the receiving nurse about this history to ensure appropriate postoperative care.
Choice B rationale:
Soft abdomen, absent bowel sounds, no bleeding on dressing. Rationale: While this information is important for assessing the client's postoperative status, it is less urgent than the history of vomiting. The abdominal assessment suggests normal findings after surgery.
Choice C rationale:
Declining to take ice chips for complaints of dry mouth. Rationale: While this information indicates the client's complaint of dry mouth, it is not as critical as the history of vomiting or the assessment of surgical outcomes.
Choice D rationale:
Peripheral pulses present with full range of motion of both legs. Rationale: This information is important but primarily related to the client's vascular and neurological status. It may not be as immediately relevant as the history of vomiting in the context of a recent surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Activate the lockdown procedure.
Choice A rationale:
Asking the mother about expected visitors is important for later investigation, but it does not address the immediate concern of a potentially missing infant and delays necessary security measures.
Choice B rationale:
Matching ID bands is an essential step in verifying the identity of infants and mothers, but it should follow initial actions to secure the area and prevent possible abduction.
Choice C rationale:
Determining if the newborn is in the nursery is a logical step but not the first priority. The immediate action should be to secure the unit to prevent any potential abductor from leaving.
Choice D rationale:
Activating the lockdown procedure is the first priority to ensure the safety of the infant and prevent any unauthorized individuals from leaving the facility. This step is crucial to quickly address the situation and prevent potential abduction.
Correct Answer is A
Explanation
Choice A rationale:
History of vomiting at home for 3 days prior to surgery. Rationale: This information is relevant to the client's surgical history and may impact their current condition. It is essential to inform the receiving nurse about this history to ensure appropriate postoperative care.
Choice B rationale:
Soft abdomen, absent bowel sounds, no bleeding on dressing. Rationale: While this information is important for assessing the client's postoperative status, it is less urgent than the history of vomiting. The abdominal assessment suggests normal findings after surgery.
Choice C rationale:
Declining to take ice chips for complaints of dry mouth. Rationale: While this information indicates the client's complaint of dry mouth, it is not as critical as the history of vomiting or the assessment of surgical outcomes.
Choice D rationale:
Peripheral pulses present with full range of motion of both legs. Rationale: This information is important but primarily related to the client's vascular and neurological status. It may not be as immediately relevant as the history of vomiting in the context of a recent surgery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.