The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, “The client has an intravenous (IV) infusion of 1000 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?
A.
History of vomiting at home for 3 days prior to surgery.
B.
Declining to take ice chips for complaints of dry mouth.
C.
Soft abdomen, absent bowel sounds, no bleeding on dressing.
D.
Peripheral pulses present with full range of motion of both legs.
The correct answer and Explanation is :
The correct answer is B. Declining to take ice chips for complaints of dry mouth.
Explanation:
When caring for a post-operative client, particularly following a right hemicolectomy, it is crucial to assess the client’s ability to tolerate oral intake and their hydration status. In this scenario, the client is experiencing a complaint of dry mouth and is declining to take ice chips, which can indicate several potential issues:
- Hydration Status: A dry mouth suggests that the client may be dehydrated, especially considering they have an IV infusion running, but still may not be adequately hydrated. This can lead to complications such as decreased urine output and potential kidney impairment.
- Nausea Management: The client has received ondansetron recently, and while it is effective for nausea, the decision to decline oral fluids can be concerning. It raises questions about the client’s overall comfort and ability to manage nausea post-operatively.
- Postoperative Recovery: After abdominal surgery, the ability to tolerate oral intake is critical for recovery. Declining ice chips may indicate that the client is not yet ready to progress to a regular diet, which can affect their recovery trajectory.
- Patient Satisfaction and Comfort: Acknowledging and addressing complaints such as dry mouth is important for overall patient satisfaction and comfort. It is essential for nurses to manage symptoms effectively to enhance recovery and reduce the risk of complications.
In contrast, the other options, while relevant, do not have as immediate an impact on the client’s safety and recovery process. A history of vomiting (A) may be significant but is less pressing in this immediate context. A soft abdomen with absent bowel sounds (C) is expected post-surgery, and peripheral pulses with full range of motion (D) indicate adequate perfusion, which is also a positive sign. Thus, obtaining information on the client’s refusal to take ice chips is paramount for addressing their hydration and comfort needs.