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 C
Explanation
Choice A rationale:
A colostomy is a surgical opening in the abdomen that allows stool to pass through the colon and out of the body. While a colostomy may increase the risk of certain complications, such as dehydration and skin irritation, it does not directly increase the risk of aspiration. This is because the colostomy bypasses the upper digestive tract, where aspiration typically occurs.
Choice B rationale:
An ileostomy is a similar surgical opening in the abdomen, but it diverts the small intestine rather than the colon. Like a colostomy, an ileostomy does not directly increase the risk of aspiration. However, it may lead to dehydration and electrolyte imbalances, which could indirectly contribute to aspiration risk.
Choice C rationale:
Enteral feedings through an NG tube are a common way to provide nutrition to patients who cannot eat by mouth. However, these feedings can also increase the risk of aspiration. This is because the NG tube bypasses the normal swallowing mechanisms, which help to protect the airway. If the feeding tube is not properly positioned or if the patient has impaired gastric motility, formula could enter the lungs and cause aspiration pneumonia.
Choice D rationale:
A chest tube is a drainage tube that is inserted into the chest cavity to remove air or fluid. While a chest tube may cause some discomfort and respiratory issues, it does not directly increase the risk of aspiration.
Correct Answer is C
Explanation
Choice A rationale:
Intractable pain is pain that is persistent and does not respond to usual pain management methods. While angina can be intractable in some cases, it does not typically manifest as pain in the arm and jaw. Moreover, the patient in this scenario has not yet undergone pain management efforts, so it's premature to classify the pain as intractable.
Choice B rationale:
Phantom pain is pain that is felt in a part of the body that has been amputated or is no longer there. The patient in this scenario has not experienced any amputations, so phantom pain is not a valid explanation for the arm and jaw pain.
Choice C rationale:
Referred pain is pain that is felt in a part of the body that is different from the source of the pain. This is the most likely explanation for the arm and jaw pain in this patient. The heart and the arm and jaw share nerve pathways, so pain signals from the heart can be misinterpreted by the brain as coming from these other areas. This is a common phenomenon in patients with angina.
Choice D rationale:
Cramping pain is a type of pain that is often described as a muscle tightening or squeezing sensation. It is not typically associated with angina. While angina can sometimes cause chest tightness, it's not characterized by cramping in the arm and jaw.
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