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.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale:

Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.

Choice B rationale:

Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.

Choice C rationale:

Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.

Choice D rationale:

Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.

A. "This medication will help regulate my mood and anxiety.". B. "I should expect to see immediate results after taking this medication.". C. "I may experience side effects such as nausea and drowsiness.". D. "It's important to take this medication consistently as prescribed.". E. "It's important to take this medication consistently as prescribed.".

Correct Answer is B

Explanation

Choice A rationale:

The statement, "This medication will help regulate my mood and anxiety," is an accurate description of how antidepressants work. Antidepressants can help improve mood and reduce anxiety symptoms over time.

Choice B rationale:

This is the correct answer. Expecting immediate results from antidepressant medication is a misunderstanding. Antidepressants typically take several weeks to show their full therapeutic effects. Clients need to be informed about the delayed onset of action.

Choice C rationale:

The statement, "I may experience side effects such as nausea and drowsiness," is accurate. Antidepressants can indeed cause side effects, including gastrointestinal symptoms like nausea and drowsiness. This information is essential for the client to be aware of.

Choice D rationale:

This statement is correct. It is crucial to take antidepressant medication consistently as prescribed for the best therapeutic outcomes. Stopping or missing doses without consulting a healthcare provider can lead to treatment ineffectiveness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

Correct Answer is D

Explanation

A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching?

Correct Answer is B

Explanation

After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects?

A child who weighs 55 pounds receives a prescription for cefotaxime 150 mg/kg/day intravenously in divided doses every 6 hours. How many mg should the nurse administer each day?

Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Patient Data Exhibits The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?