A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?
Document the episode
Encourage the client to eat dry toast
Allow the client to rest
Auscultate lung sounds
The Correct Answer is D
Rationale for Choice A:
Documentation is essential for communication and continuity of care, but it is not the most immediate priority in this situation.
The nurse should document the episode of vomiting, including the time, amount, and characteristics of the vomitus, as well as any associated symptoms or interventions.
However, auscultating lung sounds should be done first to assess for potential aspiration, which is a more urgent concern.
Rationale for Choice B:
Offering dry toast may be appropriate after the nurse has assessed for aspiration and determined that it is safe for the client to resume oral intake.
However, it is not the most important action at this time.
The nurse should first assess the client's respiratory status and address any potential complications.
Rationale for Choice C:
Rest is important for healing and recovery, but it is not the most immediate priority in this situation. The nurse should first assess the client's respiratory status and address any potential complications. Once the client is stable, the nurse can then encourage rest.
Rationale for Choice D:
Auscultating lung sounds is the most important action for the nurse to take after a client vomits.
This is because aspiration of vomitus is a serious complication that can lead to pneumonia, respiratory distress, and even death.
By auscultating lung sounds, the nurse can assess for signs of aspiration, such as crackles, wheezing, or diminished breath sounds.
If aspiration is suspected, the nurse can initiate appropriate interventions, such as suctioning, oxygen therapy, and positioning the client to facilitate drainage of secretions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While a young patient who lives alone may need some assistance with post-discharge care, they have nearby family and friends who can likely provide this support. This patient's situation does not present the same level of complexity and risk as the other patients described in the options.
The presence of nearby family and friends can offer practical and emotional support, helping with tasks such as transportation, meal preparation, and medication management. This social support network can play a crucial role in ensuring a smooth transition from the hospital to home.
Additionally, the patient's young age suggests a higher likelihood of physical and cognitive abilities that can facilitate self-care and adherence to discharge instructions.
Choice B rationale:
The older adult who lives alone and has memory loss has the greatest need for the nurse to consult with other members of the healthcare team regarding post-discharge care. This patient's situation presents several significant challenges that necessitate a collaborative approach to ensure safety and well-being:
Memory loss: The patient's memory loss may impair their ability to follow discharge instructions, manage medications, and maintain personal safety. This raises concerns about potential medication errors, missed appointments, and risks of falls or accidents.
Living alone: The patient's lack of immediate support at home further compounds these risks. Without someone to provide reminders, assistance with tasks, or monitoring for changes in health status, the patient's vulnerability increases.
Potential for social isolation: Living alone with memory loss can also lead to social isolation, which can negatively impact mental and physical health.
Choice C rationale:
While a married young adult who is the primary caregiver for children may face challenges in balancing their own recovery with caregiving responsibilities, they have a spouse who can provide support and assistance. This patient's situation does not present the same degree of risk as the older adult with memory loss living alone.
Choice D rationale:
The middle-aged patient who has undergone knee replacement and requires physical therapy will need support and guidance, but their needs are primarily focused on physical rehabilitation and pain management. These needs can often be addressed through standard discharge planning and coordination with physical therapy services.
Correct Answer is D
Explanation
Choice A rationale:
While working in a facility affiliated with a medical or nursing school can offer opportunities for professional development and collaboration, it is not the most important factor to consider when choosing a new job.
Affiliation with a school does not guarantee a positive work environment, strong nursing leadership, or a commitment to quality patient care, which are all hallmarks of Magnet hospitals.
It's essential to consider other factors that directly impact job satisfaction, patient outcomes, and overall nursing excellence.
Choice B rationale:
Having the latest technology can be beneficial, but it does not ensure a supportive work environment or a high standard of nursing care.
Technology is only one aspect of a hospital's operations, and it should not be the primary focus when making a career decision. It's crucial to prioritize factors that directly influence the quality of nursing practice and patient outcomes.
Choice C rationale:
Inquiring about nurse-client ratios is important, as it can provide insight into the workload and staffing levels at a hospital. However, it's not the most comprehensive indicator of a hospital's commitment to nursing excellence.
Magnet status, in contrast, signifies a broader commitment to quality nursing care, professional development, and positive work environments.
Choice D rationale:
Magnet status is a prestigious designation awarded by the American Nurses Credentialing Center (ANCC) to hospitals that demonstrate excellence in nursing care, leadership, and innovation.
Magnet hospitals are known for:
Attracting and retaining highly qualified nurses Fostering a culture of collaboration and teamwork Investing in professional development and growth
Promoting evidence-based practice and quality improvement Demonstrating outstanding patient outcomes
Seeking employment at a Magnet hospital is strongly recommended for nurses who prioritize professional growth, job satisfaction, and the delivery of exceptional patient care.
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