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.” What action should the nurse take first?
Elevate the client’s head of bed.
Offer the client apple juice.
Auscultate the client’s abdomen.
Order a lunch tray for the client.
The Correct Answer is C
Choice A rationale:
Elevating the head of the bed can promote comfort and ease breathing, but it's not the first priority in this situation. The nurse needs to assess the client's gastrointestinal status before offering any fluids or food.
While elevating the head of the bed may be helpful in some postoperative situations, it doesn't directly address the client's request for something to drink or the need to assess for potential contraindications to oral intake.
It's important to prioritize assessment before intervention to ensure safe and effective care.
Choice B rationale:
Offering apple juice, a clear liquid, might seem appropriate given the postoperative orders, but it's premature without first assessing the client's abdomen.
Auscultation can reveal important information about bowel sounds, which can indicate whether the client's gastrointestinal system is ready to tolerate fluids or food.
Prematurely offering fluids could lead to complications like nausea, vomiting, or aspiration if the client's bowels are not functioning properly.
Choice D rationale:
Ordering a lunch tray is not appropriate at this stage. The nurse needs to first assess the client's tolerance for clear liquids before advancing the diet.
Advancing the diet too quickly could also lead to gastrointestinal complications.
It's important to follow the postoperative orders and progress the diet gradually as tolerated.
Choice C rationale:
Auscultating the client's abdomen is the essential first step in this scenario. It allows the nurse to gather crucial data about the client's gastrointestinal status.
By listening to bowel sounds, the nurse can determine if the client's intestines are active and functioning properly. If bowel sounds are present and normal, it suggests that the client is likely able to tolerate clear liquids.
If bowel sounds are absent or abnormal, it may indicate a potential problem, such as ileus (a temporary paralysis of the intestines), and the nurse would need to hold oral intake and notify the healthcare provider.
This assessment provides essential information to guide the nurse's subsequent actions and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.
In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.
It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.
Choice B rationale:
A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.
A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.
Choice C rationale:
A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:
Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.
A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.
Correct Answer is D
Explanation
Choice A rationale:
It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).
Early ambulation is generally encouraged to promote circulation and prevent blood clots.
Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.
Choice B rationale:
Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.
The patient's position should be based on their individual needs and comfort level.
In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.
Choice C rationale:
Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.
This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.
Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.
Choice D rationale:
Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.
This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.
If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.
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