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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.

Choice B rationale:

Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

Choice C rationale:

Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

Choice D rationale:

Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

A. Prescribe medication for immediate relief. B. Educate the client about various relaxation techniques. C. Assist the client in challenging irrational thoughts. D. Develop measurable and realistic outcomes. E. Develop measurable and realistic outcomes.

Correct Answer is D

Explanation

Choice A rationale:

Prescribing medication for immediate relief is not the primary goal when establishing a therapeutic relationship with a client with anxiety disorder. While medication may be a part of the treatment plan, the primary focus should be on building trust and addressing the client's emotional needs.

Choice B rationale:

Educating the client about various relaxation techniques can be beneficial, but it is not the primary goal of establishing a therapeutic relationship. The primary goal is to create a trusting and supportive environment in which the client feels comfortable discussing their feelings and concerns.

Choice C rationale:

Assisting the client in challenging irrational thoughts is an important aspect of cognitive-behavioral therapy, but it is not the primary goal of establishing the therapeutic relationship. Building rapport and trust come first.

Choice D rationale:

Developing measurable and realistic outcomes is the primary goal when establishing a therapeutic relationship. These outcomes provide a framework for assessing progress and ensuring that the therapeutic interventions are effective in addressing the client's anxiety disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is C

Explanation

A nurse is establishing a therapeutic relationship with a client with anxiety disorder. What is the primary goal of this intervention?

Correct Answer is D

Explanation

A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions?

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).

A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?