The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?

Asking for nausea

Evaluating for sacral redness

Checking the respiratory rate

Auscultating bowel sounds

Answer and Explanation

The Correct Answer is C

Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.

By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.

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Correct Answer is D

Explanation

Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.

Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.

A. The patient uses crutches with a swing-to gait. B. The patient sits straight up on the edge of the bed. C. the patient bends over the sink while brushing teeth. D. The patient leans forward to pull on shoes and socks

Correct Answer is C

Explanation

The patient bending over the sink while brushing teeth requires intervention by the nurse. After hip arthroplasty using the posterior approach, the patient should avoid bending at the hip greater than 90 degrees to prevent dislocation of the prosthesis. The nurse should instruct the patient to bend at the knees instead of the hips while brushing teeth or doing any other activity that requires bending. The other actions mentioned in the options are appropriate for a patient after hip arthroplasty.

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The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings will the nurse anticipate in the client with cholelithiasis?

Correct Answer is D

Explanation

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

Correct Answer is C

Explanation

The nurse is providing education to a client who is prescribed Lisinopril (ACE inhibitor) for hypertension. The nurse will be sure to include what information about a common side effect?

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The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?

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