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 B

Explanation

Venous thromboembolism refers to the formation of blood clots in the veins, which can lead to serious complications such as pulmonary embolism. After surgery, immobility and reduced activity can increase the risk of developing blood clots. Therefore, it is crucial to prioritize measures to prevent venous thromboembolism, such as early mobilization, compression stockings, and anticoagulant medications, to ensure the patient's safety and well-being.

A. Fever, tachypnea, and tachycardia B. Frequent stools, weight loss, and hyperactive bowels C. Frequent stools, fever, and tachycardia D. Constipation, fever, and weight loss

Correct Answer is B

Explanation

IBD, which includes conditions such as Crohn's disease and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. The symptoms can vary depending on the type and severity of the disease, but common symptoms in children with IBD include:

Children with IBD often experience increased frequency of bowel movements, which may be loose or watery. This is often accompanied by urgency and a sense of incomplete evacuation.
Chronic inflammation in the gastrointestinal tract can interfere with nutrient absorption, leading to poor appetite, decreased intake, and subsequent weight loss. In severe cases, malnutrition may occur.
Inflammatory processes in the intestines can lead to increased motility and peristalsis, resulting in hyperactive bowel sounds.

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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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Naxlex Comprehensive Predictor Exams

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