A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

Explore non-pharmacological options for nausea

Offer to notify the healthcare provider after morning rounds are completed

Discuss how anesthesia can cause nausea after surgery

Explain to the patient that nothing else has been ordered

Answer and Explanation

The Correct Answer is A

Choice A reason: Non-pharmacological options, like acupressure or aromatherapy, address nausea without medication risks. These interventions stimulate the parasympathetic nervous system or reduce gastric irritation, providing relief. Acting first with these methods is safe, effective, and aligns with holistic care, especially when the next antiemetic dose is not yet due.

Choice B reason: Notifying the provider after rounds delays intervention, as nausea requires prompt relief to prevent distress or vomiting. This approach does not address the client’s immediate need and may prolong discomfort. Non-pharmacological methods should be tried first, as they are within the nurse’s scope and can provide quicker relief.

Choice C reason: Discussing anesthesia’s role in nausea provides education but does not alleviate the client’s current symptoms. This cognitive approach addresses understanding, not immediate comfort. While education is valuable, the priority is relieving nausea, making non-pharmacological interventions a more appropriate first step in this scenario.

Choice D reason: Explaining that no other medications are ordered dismisses the client’s discomfort and does not provide relief. This approach fails to utilize the nurse’s scope to implement non-pharmacological interventions, which can effectively manage nausea. It may also reduce trust, as it does not address the client’s immediate needs.

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Correct Answer is A

Explanation

Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.

Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.

Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.

Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.

A. Take the client for a walk and ask them to talk about their family B. Administer alprazolam to decrease their anxiety C. Administer olanzapine to decrease their agitation D. Take the client to their room so they will not upset others

Correct Answer is A

Explanation

Choice A reason: Engaging the client in a walk and family discussion uses therapeutic communication and redirection, common in dementia care. This non-pharmacological approach validates emotions, reduces distress, and promotes calmness by shifting focus to positive memories, aligning with person-centered care principles to address emotional needs first.

Choice B reason: Alprazolam, a benzodiazepine, reduces anxiety but carries risks like sedation and falls in dementia patients. Pharmacological interventions should be secondary to non-pharmacological approaches, as they may exacerbate confusion or dependency. Addressing emotional distress through engagement is preferred before considering medications for anxiety management.

Choice C reason: Olanzapine, an antipsychotic, is used for severe agitation or psychosis in dementia. It poses risks like sedation, extrapyramidal symptoms, and increased mortality in elderly patients. Non-pharmacological interventions, like redirection, are prioritized to manage emotional distress safely, reserving medications for when behavioral approaches fail.

Choice D reason: Isolating the client in their room may increase distress and agitation in dementia patients, as it does not address their emotional needs. Social isolation can worsen confusion and feelings of abandonment. Therapeutic engagement, such as redirection or validation, is more effective in calming the client and fostering trust.

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A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Correct Answer is A

Explanation

A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing a client for a lumbar puncture. Which position should the nurse place the client in to facilitate the procedure?

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indicate the nurse is addressing the affective domain of learning?

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