The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Place a warm blanket on the client.

Administer IV fluids per protocol.

Review the medication administration record.

Check the urinary catheter r an occlusion.

Answer and Explanation

The Correct Answer is B

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale for correct choices:

• Increase your water and fiber intake while taking opioids: Opioids frequently cause constipation by slowing gastrointestinal motility. Encouraging adequate hydration and fiber intake helps prevent constipation and maintain bowel regularity, which is an essential part of opioid education.

• Expect the morphine to take 1 to 2 hours for full effect: IV morphine typically takes effect within 5 to 10 minutes, with peak analgesic effect in about 20 minutes. Telling the client it takes 1 to 2 hours may cause confusion and unnecessary delay in using other comfort measures.

• Request pain medication only if pain is severe: Waiting until pain is severe can result in poor pain control and decreased participation in respiratory exercises. Encouraging timely administration before pain becomes severe promotes better analgesia and facilitates lung expansion.

• Use incentive spirometer when the pain medication takes effect: Pain can limit the client’s ability to perform deep breathing exercises. Using the incentive spirometer when analgesia is effective promotes lung expansion, reduces atelectasis risk, and improves oxygenation in clients with rib fractures.

• Ask for assistance when getting out of bed after taking morphine: Morphine can cause dizziness, orthostatic hypotension, or sedation, increasing fall risk. Asking for assistance ensures client safety during ambulation or position changes, especially in older adults with recent trauma.

A. Note and report the client's food and liquid intake during meals and snacks. B. Assess the client for weakness and fatigue. C. Report any client mention of pain or discomfort. D. Weigh the client and report any weight gain. E. Evaluate the client for sleep disturbances.

Correct Answer is ["A","C","D"]

Explanation

A. Note and report the client's food and liquid intake during meals and snacks: UAPs can monitor and document intake and output, then report to the nurse for evaluation. This is within their role.

B. Assess the client for weakness and fatigue: Assessment requires nursing judgment and interpretation of findings, which cannot be delegated to UAPs.

C. Report any client mention of pain or discomfort: UAPs may report observations or client statements to the nurse. The nurse is responsible for further assessment and management.

D. Weigh the client and report any weight gain: Daily weights and reporting results are appropriate UAP tasks, as they are routine and measurable without requiring clinical judgment.

E. Evaluate the client for sleep disturbances: Evaluation involves analysis and clinical decision-making, which must be performed by the nurse, not the UAP.

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The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Nursing Test Bank

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Patient Data Exhibits The nurse is providing education about opioid pain medication. For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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Explanation

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