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. "Eating yogurt can help decrease gas odor that I have."
This is the correct choice. Yogurt contains probiotics, which can contribute to a healthy balance of bacteria in the digestive system, potentially reducing gas odor associated with a colostomy.

B. "I should eliminate pasta from my diet so that I don’t have as many loose stools."
This statement is incorrect. Pasta, as a general rule, is not associated with causing loose stools. Dietary adjustments should be individualized, and specific triggers for loose stools vary among individuals.

C. "My largest meal of the day should be in the evening."
While meal timing can vary based on personal preferences and lifestyle, there is no strict rule that the largest meal must be in the evening. It depends on individual habits and dietary needs.

D. "Carbonated beverages can help control odor."
This statement is incorrect. Carbonated beverages are not typically associated with controlling odor related to a colostomy. In fact, they may contribute to increased gas production, potentially exacerbating odor issues.

A. Check that the client lifts the walker and then places it down in front of her. B. Walk in front of the client to guide her in moving the walker. C. Have the client move one leg forward with the walker. D. Make sure that the upper bar of the walker is level with the client’s waist.

Correct Answer is A

Explanation

A. Check that the client lifts the walker and then places it down in front of her.

To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.

B. Walk in front of the client to guide her in moving the walker.

The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.

C. Have the client move one leg forward with the walker.

The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.

D. Make sure that the upper bar of the walker is level with the client’s waist.

The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?

Correct Answer is A

Explanation

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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