A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions is the priority for the nurse to take?
Provide an antiemetic.
Make the client NPO.
Administer a stimulant laxative.
Auscultate bowel sounds.
The Correct Answer is D
A. Provide an antiemetic.
While providing an antiemetic can help alleviate the client's nausea and vomiting, it is not the priority action. Assessment should come first to determine the underlying cause.
B. Make the client NPO.
Making the client NPO might be necessary if there is concern about bowel obstruction or other gastrointestinal issues, but this decision should be based on an initial assessment, such as auscultating bowel sounds.
C. Administer a stimulant laxative.
Administering a stimulant laxative is not appropriate at this stage without first assessing bowel sounds. It could potentially worsen the situation if there is a bowel obstruction.
D. Auscultate bowel sounds.
The priority in this situation is to assess for possible complications such as bowel obstruction or paralytic ileus, which can occur postoperatively and can be exacerbated by opioid use. Auscultating bowel sounds helps determine the presence of normal, hypoactive, or absent bowel sounds, guiding further management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “Use sugar-free gum if you experience a metallic taste in your mouth.”
This is the appropriate choice. Chemotherapy can cause a metallic taste in the mouth, and using sugar-free gum or candies can help alleviate this taste disturbance.
B. “Drink fluids at mealtime to prevent early satiety.”
This statement is not advisable. Drinking fluids at mealtime may lead to early satiety, making it challenging for the client to consume adequate nutrition. It is generally recommended to drink fluids between meals.
C. “Foods that are higher in fat can help nausea.”
This statement is not accurate. High-fat foods may exacerbate nausea for some individuals undergoing chemotherapy. The focus during periods of nausea is often on easily digestible, low-fat, and bland foods.
D. “Raw fruits and vegetables will be easier for your body to digest.”
This statement is not accurate. Raw fruits and vegetables may be harder to digest, and during chemotherapy, the digestive system can be sensitive. It is generally recommended to choose cooked or processed fruits and vegetables for easier digestion.
Correct Answer is D
Explanation
A. Yogurt:
Yogurt is not a significant source of iron. While yogurt provides various nutritional benefits, it is not considered an iron-rich food.
B. Oranges:
Oranges are a good source of vitamin C, which enhances the absorption of non-heme iron from plant-based foods. However, oranges themselves do not contain substantial amounts of iron. The combination of vitamin C-rich foods with iron-rich foods can be beneficial for iron absorption.
C. Turnips:
Turnips are a vegetable that, while nutritious, is not particularly high in iron. Additionally, the iron in plant-based foods like turnips is non-heme iron, which is less easily absorbed by the body compared to heme iron found in animal products.
D. Roast beef:
Roast beef is a good source of heme iron, which is more easily absorbed by the body. Red meat, such as roast beef, is a valuable dietary source of iron, especially for individuals with iron deficiency.
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