A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?
Order a lunch tray for the client.
Offer the client apple juice.
Auscultate the client's abdomen.
Elevate the client's head of bed.
The Correct Answer is C
A. Order a lunch tray for the client. Before advancing the diet, it is important to assess the client's readiness, particularly bowel sounds.
B. Offer the client apple juice. Providing liquids is appropriate only after assessing the client's gastrointestinal function.
C. Auscultate the client's abdomen: This assessment checks for the return of bowel sounds and gastrointestinal function, indicating whether the client can tolerate clear liquids.
D. Elevate the client's head of bed. While positioning is important, the primary first step is to assess the client's gastrointestinal status
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dispose of the needle uncapped: The safest method to avoid needle-stick injuries and potential exposure to bloodborne pathogens, including hepatitis C, is to dispose of the needle immediately without recapping.
B. Ask another nurse to recap the needle: Asking another nurse to recap the needle still poses a risk of needle-stick injury and is not a recommended practice.
C. Place the cap on the table and slide the needle into the cap: This method, known as the "scoop" technique, reduces the risk compared to hand recapping but is still not the best practice. Proper sharps disposal is the preferred method.
D. Recap the needle: Recapping needles is discouraged due to the high risk of accidental needle-stick injuries.
Correct Answer is A
Explanation
A. Observe the client. The first priority is to monitor the client for any adverse reactions or side effects from the wrong medication.
B. Complete an incident report. While important, the incident report is not the first action to take.
C. Notify the nurse manager. Informing the nurse manager is necessary, but not the immediate first step.
D. Call the client's provider. Notifying the provider is also important but observing the client for any immediate effects takes precedence.
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