A client reports, “I have not had a bowel movement in 4 days and I have vomited once or twice.”. Given the client’s cardiovascular and gastrointestinal status, and social history, what should the nurse plan to do first?
Request a prescription for an antiemetic.
Determine if the nasogastric tube is in the correct position.
Increase the nasogastric tube suction.
Reposition the nasogastric tube.
The Correct Answer is B
Choice A rationale
While an antiemetic might help with the vomiting, it would not address the underlying issue of not having a bowel movement for 4 days. Therefore, this choice is incorrect.
Choice B rationale
If the client has a nasogastric tube, checking its position would be a good first step. If the tube is not in the correct position, it could be causing or contributing to the client’s symptoms.
Therefore, this choice is correct.
Choice C rationale
Increasing the suction on a nasogastric tube might help if the tube is functioning correctly and the problem is related to stomach contents not being properly evacuated. However, it would not be the first step before checking the position of the tube. Therefore, this choice is incorrect.
Choice D rationale
Repositioning the nasogastric tube might be necessary if it’s not in the correct position, but this would not be the first step before checking its position. Therefore, this choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Without specific patient data, it’s challenging to provide a detailed rationale.
However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.
Choice B rationale
Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.
Choice C rationale
Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.
Choice D rationale
Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.
Correct Answer is C
Explanation
Choice A rationale
Discontinuing the nasogastric tube is not the best action to take at this time. The nasogastric tube may be necessary for decompression of the stomach or administration of medications and should not be removed without a specific order from the healthcare provider.
Choice B rationale
Providing the client with ice chips is not the most appropriate action. The client is kept NPO (nothing by mouth) before surgery to prevent aspiration during anesthesia. Therefore, giving the client ice chips could increase the risk of aspiration.
Choice C rationale
Starting the prescribed antibiotic is the correct action. Cefazolin is an antibiotic that is often given before surgery to prevent postoperative infections. Administering this medication as ordered can help to ensure that the client is adequately prepared for surgery.
Choice D rationale
While reinforcing preoperative teaching is an important part of nursing care, it is not the most immediate action that should be taken in this situation. The client’s physical preparation for surgery, including the administration of prescribed medications, should be prioritized.
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