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 A
Explanation
Choice A rationale:
Assigning a client who is one day postoperative for a laparoscopic cholecystectomy to the practical nurse (PN) is appropriate. This procedure is minimally invasive, and the client is likely stable, requiring routine postoperative care such as wound assessment, pain management, and monitoring for any signs of complications.
Choice B rationale:
An older client who is one day postoperative with a colostomy for colon cancer may have complex postoperative needs, including colostomy care, monitoring for complications, and pain management. This level of care is usually within the scope of the registered nurse (RN) rather than a practical nurse (PN).
Choice C rationale:
An older adult who is scheduled for foot amputation due to diabetes complications is likely to have complex care needs, including wound care, diabetes management, and potential complications. This client would require the expertise of an RN rather than a PN.
Choice D rationale:
An adult with alcoholism, cirrhosis, and hepatic encephalopathy may have complex medical and psychosocial issues that require specialized nursing care. This client's condition is not appropriate for a practical nurse (PN) to manage, and the care should be provided by an RN or other specialized healthcare provider.
Correct Answer is B
Explanation
Choice A rationale:
Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.
Choice B rationale:
Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.
Choice C rationale:
Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.
Choice D rationale:
Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.
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