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:
Pallor, or paleness, is not a typical sign of phlebitis. It can be associated with other conditions such as anemia, decreased blood flow, or shock. In the context of IV therapy, pallor at the insertion site might suggest a problem with blood flow, such as infiltration or a clot, but it's not a direct indication of inflammation.
Choice B rationale:
Coolness at the IV site is also not a characteristic sign of phlebitis. It could potentially suggest infiltration of the IV fluids into the surrounding tissues, but it's not a primary indicator of inflammation. Phlebitis typically involves warmth and redness due to the inflammatory response.
Choice C rationale:
Erythema, or redness, is the hallmark sign of phlebitis. It's caused by the dilation of blood vessels in the area as part of the inflammatory response. The redness is often accompanied by warmth, swelling, and tenderness along the vein.
Mechanism of erythema in phlebitis:
When the inner lining of the vein (endothelium) is irritated or damaged by the IV catheter, it releases inflammatory mediators. These mediators cause the blood vessels to dilate, leading to increased blood flow and redness in the area.
The redness is often more pronounced along the path of the vein, rather than just at the insertion site.
Choice D rationale:
Drainage from the IV site can be a sign of infection, but it's not a primary feature of phlebitis. If drainage is present, it's important to assess for other signs of infection, such as pus, fever, or increased pain.
Correct Answer is D
Explanation
Choice A rationale:
Notifying the facility's security department may be necessary in some cases, but it should not be the nurse's first action. This could escalate the situation and make the patient feel threatened or coerced. It's important to first attempt to de-escalate the situation and understand the patient's reasons for wanting to leave. Involving security prematurely could damage the nurse- patient relationship and make it more difficult to provide care in the future.
Security should be involved if the patient is a danger to themselves or others, or if they are attempting to leave in a way that could cause harm. However, in most cases, it is best to try to resolve the situation through communication and understanding.
Choice B rationale:
Calling the patient's family may be helpful in some cases, but it is not always necessary or appropriate. The nurse should first assess the patient's decision-making capacity and their understanding of the risks of leaving against medical advice. If the patient is capable of making their own decisions, the nurse should respect their autonomy and not involve family members without their consent.
Involving family members without the patient's consent could breach confidentiality and erode trust. It's important to balance the patient's right to privacy with the potential benefits of involving family members.
Choice C rationale:
Insisting that the patient exit the hospital via a wheelchair is not necessary in most cases. If the patient is able to walk and does not pose a safety risk, they should be allowed to leave on their own terms. Requiring a wheelchair could be seen as patronizing or controlling, and it could further upset the patient.
The use of a wheelchair should be based on the patient's individual needs and preferences, not on a blanket policy.
Choice D rationale:
Making sure the patient understands that they are leaving against medical advice is the most important action the nurse can take. This ensures that the patient is aware of the potential risks of leaving the hospital, and it protects the nurse from liability. The nurse should document the patient's decision in the medical record and have the patient sign an Against Medical Advice (AMA) form.
By ensuring informed consent, the nurse respects the patient's autonomy while also fulfilling their professional obligations.
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