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    Hesi RN Exit Proctored ExamQuestion 43
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    Hesi RN Exit 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. Declining to take ice chips despite reporting of dry mouth: While this is noteworthy, it is less critical than abdominal assessment findings for a postoperative laparotomy client. B. Peripheral pulses present with full range of motion of both legs: This is important for assessing circulation and mobility but is less urgent than the abdominal assessment in this context. C. History of vomiting at home for 3 days prior to surgery: Although relevant to the overall medical history, this information is not as immediately critical in the postoperative period compared to the current physical findings. D. Soft abdomen, absent bowel sounds, no bleeding on dressing: Postoperative assessment of the abdomen is crucial for clients who have undergone abdominal surgery. The presence or absence of bowel sounds and the condition of the surgical site are vital pieces of information that need to be communicated to ensure continuity of care and to monitor for complications such as paralytic ileus or infection.

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