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    HESI PN Exit 2023 II Proctored Exam

    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?

    Explanation & Rationale

    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.

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