A nurse is caring for a client who is 16 hr postoperative and is experiencing abdominal gas pains. Which of the following actions should the nurse take?

Encourage the client to use an incentive spirometer.

Assist the client with ambulation.

Provide the client with low-fiber food.

Administer pain medication to the client.

Answer and Explanation

The Correct Answer is B

A. Using an incentive spirometer is important for improving lung function and preventing atelectasis, but it does not directly address abdominal gas pains.

B. Assisting the client with ambulation is the best action to alleviate abdominal gas pains. Walking helps stimulate peristalsis and can promote the passage of gas, reducing discomfort.

C. Low-fiber food is not recommended for managing abdominal gas pains postoperatively. In fact, high-fiber foods can help prevent constipation and promote bowel movement, which is beneficial for relieving gas.

D. Administering pain medication may be appropriate if the client is in significant pain, but addressing the underlying cause of the pain (gas) by encouraging ambulation is more effective for long-term relief.

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Correct Answer is B

Explanation

A. Flumazenil is an antidote for benzodiazepine overdose, not opioid overdose. The client is receiving morphine, an opioid, so flumazenil is not appropriate.

B. Naloxone is the correct antidote for opioid overdose, including morphine. It works by reversing the effects of opioids, such as respiratory depression and hypotension. Given the client's low respiratory rate and blood pressure, naloxone should be administered immediately to reverse the opioid effects.

C. Acetylcysteine is used for acetaminophen (Tylenol) overdose, not opioid overdose.

D. Protamine sulfate is used to reverse the effects of heparin (an anticoagulant), not opioids. It is not appropriate for this situation.

A. Administer the transfusion through a 25-gauge saline lock. B. Administer the plasma immediately after thawing. C. Transfuse the plasma over 4 hr. D. Hold the transfusion if the client is actively bleeding.

Correct Answer is B

Explanation

A. A 25-gauge saline lock is too small for administering fresh frozen plasma. Plasma should be transfused through a larger gauge catheter (typically 18 or 20 gauge) to ensure proper flow and minimize complications.

B. Fresh frozen plasma should be administered as soon as possible after thawing, typically within 30 minutes to 1 hour, to maintain its efficacy and avoid bacterial growth.

C. Fresh frozen plasma should not be transfused over 4 hours. It is usually given within 1 to 2 hours to minimize the risk of bacterial contamination and ensure proper clotting factor effectiveness.

D. Holding the transfusion if the client is actively bleeding is not appropriate. In fact, fresh frozen plasma is often administered to clients who are actively bleeding or who have clotting disorders to replace deficient clotting factors.

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A nurse is caring for a client who is 16 hr postoperative and is experiencing abdominal gas pains. Which of the following actions should the nurse take?

Nursing Test Bank

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