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 C

Explanation

A. Stomatitis
Stomatitis refers to inflammation of the oral mucosa, which includes the lips, cheeks, gums, tongue, and palate. It can be caused by various factors, such as infections, irritants, or systemic conditions. While stomatitis may contribute to changes in oral odor, it encompasses a broader range of inflammatory conditions within the oral cavity.

B. Gingivitis
Gingivitis is inflammation of the gums (gingiva). It is often caused by plaque buildup and can lead to redness, swelling, and bleeding of the gums. While gingivitis may contribute to bad breath, it specifically involves inflammation of the gum tissue.

C. Halitosis
Halitosis refers to bad breath or a strong mouth odor. It can be caused by various factors, including poor oral hygiene, infections, dental conditions, or systemic diseases. In the context of a client with facial fractures, the nurse might observe halitosis due to challenges in maintaining oral hygiene or potential injuries.

D. Pyorrhea
Pyorrhea is an outdated term that was historically used to describe advanced stages of periodontal disease, including inflammation of the gums and supporting structures. The term is not commonly used in modern dental or medical terminology.

A. The ropes are in the center of the wheel grooves. B. The weights rest against the foot of the bed. C. The weights are equal on each side. D. The ropes attach securely to the pin.

Correct Answer is B

Explanation

A. The ropes are in the center of the wheel grooves.

Having the ropes in the center of the wheel grooves is appropriate and ensures proper alignment within the pulley system. This is not a problem that needs correction.

B. The weights rest against the foot of the bed.

This is the correct choice for correction. Allowing the weights to rest against the foot of the bed can alter the amount of force applied to the skeletal structures and compromise the effectiveness of the traction. The weights should hang freely and move within the pulley system.

C. The weights are equal on each side.

Having equal weights on each side is generally appropriate and helps maintain proper balance in the traction system. This is not a problem that needs correction.

D. The ropes attach securely to the pin.

Secure attachment of the ropes to the pin is essential for maintaining proper traction. This is not a problem that needs correction if the attachment is secure.

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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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Correct Answer is B

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