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:
Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.
It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.
It could also disrupt the delicate balance of fluids in the wound and delay healing.
Choice B rationale:
Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.
This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.
Choice D rationale:
Emptying the reservoir once per day is not frequent enough.
The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.
Allowing the reservoir to become too full could put pressure on the wound and impede healing.
Choice C rationale:
Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.
This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.
Correct Answer is A
Explanation
Choice A rationale:
Hypovolemic shock is a life-threatening condition that occurs when the body loses a significant amount of blood or fluids, leading to a decrease in circulating blood volume. This can result in inadequate perfusion of organs and tissues, which can cause damage and even death if not treated promptly.
In this case, the athlete's symptoms and vital signs are consistent with hypovolemic shock. The athlete has been practicing twice a day in the heat, which can lead to significant fluid loss through sweating. The athlete is also dizzy, which is a common symptom of hypovolemia due to decreased blood flow to the brain. The athlete's blood pressure is low (100/2 mm Hg), pulse rate is elevated (100 beats/minute), and respiratory rate is increased (26 breaths/minute), all of which are compensatory mechanisms to try to maintain blood pressure and perfusion in the setting of hypovolemia. The athlete's skin is cool to touch
and pale in color, which is due to decreased blood flow to the skin. The athlete also does not remember the last voiding time, which may indicate decreased urine output, another sign of hypovolemia.
Key points supporting hypovolemic shock:
Significant fluid loss due to exercise in the heat Dizziness
Low blood pressure Elevated pulse rate Increased respiratory rate Cool, pale skin
Decreased urine output Additional details:
Hypovolemic shock can be caused by various factors, including:
Hemorrhage (blood loss) Severe dehydration Burns
Severe vomiting or diarrhea
Treatment for hypovolemic shock typically involves:
Intravenous fluid replacement to restore circulating blood volume Blood transfusion if the shock is due to hemorrhage
Oxygen therapy to support breathing
Medications to support blood pressure and heart function
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