Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Remove the transdermal patch until the vomiting subsides.

Reposition the transdermal patch to the client's trunk.

Explain that this is a side effect of the medication in the patch.

Notify the client's healthcare provider of the vomiting.

Answer and Explanation

The Correct Answer is D

A.   Removing the scopolamine patch is not indicated without consulting the healthcare provider.
B.   Repositioning the patch is not necessary as it is properly placed for its intended effect.
C.   While nausea and vomiting are potential side effects of scopolamine, it's important to notify the healthcare provider to determine the appropriate next steps.
D.   Notifying the healthcare provider allows for further evaluation and possible adjustment of the client's postoperative antiemetic regimen.

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Correct Answer is B

Explanation

A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.
B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.
C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.
D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

A. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is A

Explanation

A. Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B. Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C. A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

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Correct Answer is B

Explanation

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Correct Answer is A

Explanation

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