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. Close the curtains around the client’s bed.

Closing the curtains around the client's bed is a practical way to maintain the client's privacy during a bed bath. This action provides a visual barrier, ensuring that the client is shielded from the view of others in the room.

B. Close the door of the client’s room.

Closing the door is another way to enhance privacy, but it may not be as feasible in all situations. Closing the curtains provides immediate visual privacy without necessarily closing off the entire room.

C. Ask family members to leave the room.

This option is appropriate if family members are present and their presence is not essential for the bed bath. Asking them to step out temporarily can enhance the client's privacy.

D. Use a blanket to cover the client.

While using a blanket is a way to cover and provide modesty during the bed bath, closing the curtains is a more direct measure to maintain visual privacy. Blankets can be used as needed during the bed bath process.

A. Clean the perineum from front to back. B. Lubricate the catheter. C. Explain to the client that she will feel temporary discomfort. D. Arrange the sterile items on the sterile field.

Correct Answer is D

Explanation

A. Clean the perineum from front to back.

After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.

B. Lubricate the catheter.

Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.

C. Explain to the client that she will feel temporary discomfort.

Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.

D. Arrange the sterile items on the sterile field.

This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.

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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 about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client’s privacy?

Correct Answer is A

Explanation

A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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