HESI RN Exit VI Proctored Exam
The nurse on the medical-surgical unit is receiving a transfer report from the postanesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1,000 mL 0.9% sodium chloride is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg IV 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 IV every 2 hours PRN for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?
Explanation & Rationale
A. While the presence of peripheral pulses and full range of motion is important, it is typically included in the physical assessment findings and is less immediately relevant to postoperative status compared to other options. B. The history of vomiting at home is part of the client’s medical history but is not immediately relevant to the postoperative status. C. Information about the abdomen (soft, absent bowel sounds, no bleeding on dressing) is critical as it pertains directly to the surgical site and postoperative recovery. D. Declining ice chips despite reporting a dry mouth is noteworthy but less critical than assessing the surgical site and abdominal status.
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