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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Discuss a referral to home health and hospice care with the client and family.

This is the correct answer. Discussing a referral to home health and hospice care addresses the client's expressed desire to go home and provides the necessary support and care for both the client and the family during this challenging time.

B. Contact the social worker to assist with nursing home placement.

This option may not align with the client's wish to go home. Nursing home placement may not be the preferred choice, especially when the client wants to spend their final days in a home setting.

C. Talk with the provider about extending the client’s hospital stay.

Prolonging the hospital stay may not meet the client's expressed wish to go home and may not provide the same level of comfort and support as home health and hospice care.

D. Instruct the family about meeting the client’s palliative care needs at home.

While providing information about meeting palliative care needs at home is important, it is more comprehensive to involve home health and hospice services, which can provide skilled care, emotional support, and assistance to the family in managing the client's care needs at home.

A. Keep the prosthesis in direct contact with the residual limb. B. Apply a moisturizing lotion or oil to the stump daily. C. Dry the prosthesis socket completely before applying it to the limb. D. Expect some skin irritation from the prosthesis.

Correct Answer is C

Explanation

A. Keep the prosthesis in direct contact with the residual limb.

This statement is incorrect. Prosthetic care typically involves using a liner or sock between the residual limb and the prosthesis. This helps to provide cushioning, absorb sweat, and reduce friction, contributing to comfort and preventing skin irritation.

B. Apply a moisturizing lotion or oil to the stump daily.

Moisturizing the skin on the residual limb is generally advisable to prevent dryness and irritation. However, it's crucial to ensure that the skin is completely dry before attaching the prosthesis. Moisturizing can help maintain skin health and comfort.

C. Dry the prosthesis socket completely before applying it to the limb.

This statement is correct. Ensuring that the prosthesis socket is thoroughly dry before application is crucial to prevent skin irritation and ensure a secure fit. Moisture between the skin and the prosthesis can contribute to discomfort and skin-related issues.

D. Expect some skin irritation from the prosthesis.

While it is common to experience minor skin irritation initially as the individual adjusts to the prosthesis, persistent or severe irritation should be addressed. The goal is to achieve a proper fit and minimize skin-related problems through appropriate care and adjustments.

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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?

Nursing Test Bank

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