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 D
Explanation
A. The spacer increases the amount of medication delivered to the oropharynx. The spacer actually reduces the amount of medication deposited in the oropharynx, directing more to the lungs.
B. Inhale rapidly when using the spacer with the MDI. The correct technique is to inhale slowly and deeply to ensure the medication reaches the lungs.
C. Cover exhalation slots of the spacer with lips when inhaling. The lips should form a seal around the mouthpiece, but covering exhalation slots is not necessary.
D. The spacer increases the amount of medication delivered to the lungs. This is the primary benefit of using a spacer, making it the correct answer.
Correct Answer is B
Explanation
A. Keep the collection container at room temperature. The collection container should be kept refrigerated or on ice to prevent bacterial growth and preserve the sample.
B. At the beginning of the collection time, urinate and then discard the urine. This is the correct method to ensure the 24-hour collection period starts with an empty bladder.
C. At the end of the collection time, urinate and save the urine in a separate container. The final urine at the end of the collection period should be added to the collection container, not saved separately.
D. Save each urine collection in a separate container: All urine collected over the 24-hour period should be saved in the same container to provide an accurate total volume for analysis.
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