Hesi RN Exit Proctored Exam
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?
Explanation & Rationale
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.
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