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 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.
Correct Answer is B
Explanation
A. Reduction of the fracture:
Buck's traction is not primarily intended for the reduction (realignment) of the fractured bones. While it may help maintain proper alignment, the primary goal is to provide temporary immobilization and relieve muscle spasms until more definitive treatment, such as surgery, can be performed.
B. Relief from muscle spasms:
This is the correct answer. Buck's traction is commonly used to alleviate muscle spasms associated with hip fractures. The traction force helps to relax the muscles, reduce pain, and maintain the alignment of the fractured bones.
C. Alignment of the pins:
Buck's traction does not involve the insertion of pins into the bone. It uses a boot attached to the leg, and the traction force is applied externally to the limb to achieve the desired therapeutic effects.
D. Support for moving the extremity:
Buck's traction is not intended to support active movement of the extremity. Instead, it provides temporary immobilization to prevent further injury and facilitate the healing process before more definitive interventions, such as surgery, are undertaken.
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