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 C
Explanation
A. Jog or run three times a week.
This option is not a recommended joint protection strategy for osteoarthritis. High-impact activities like jogging or running can potentially exacerbate symptoms and increase stress on weight-bearing joints.
B. Choose soft, pillowed chairs for sitting.
While comfortable seating is important for general comfort, it is not a specific joint protection strategy for osteoarthritis. The emphasis for osteoarthritis management is on maintaining joint function through appropriate exercise and weight management.
C. Maintain the recommended body weight.
This is the correct choice. Maintaining the recommended body weight is a crucial joint protection strategy for individuals with osteoarthritis, as excess body weight can contribute to increased stress on weight-bearing joints, leading to worsened symptoms.
D. Reduce the amount of purine in the diet.
This recommendation is more relevant for conditions like gout, which is characterized by the deposition of uric acid crystals in joints. It is not a specific joint protection strategy for osteoarthritis.
Correct Answer is A
Explanation
A. "I’ll apply ice to my ankle for 20 minutes every hour."
This is the correct choice. Applying ice for a specified duration (20 minutes) every hour is a standard recommendation for managing swelling and pain associated with an ankle sprain. It helps reduce inflammation and provides relief.
B. "I’ll rewrap my ankle starting from the knee down."
This statement indicates a misunderstanding. When rewrapping an ankle, it should be done from the bottom (proximal) to the top (distal) to provide proper compression. Starting from the knee down is not the correct technique.
C. "I’ll walk on my ankle for 10 minutes every hour."
This statement may indicate a misunderstanding or potential for harm. Immediate weight-bearing or walking on an injured ankle, especially after a sprain, is generally not recommended. Rest is often a key component of initial management.
D. "I’ll put a heating pad on my ankle at bedtime tonight."
This statement may indicate a misunderstanding. Heat is not typically recommended in the initial stages of treating an acute injury like an ankle sprain, as it may increase inflammation. Ice (cold therapy) is usually the preferred modality early on to reduce swelling and pain.
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