A nurse is admitting a 68-year-old male client in the accident and emergency unit.

Exhibits

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.

Choice A rationale

Discussing the client's anxiety only after obtaining consent dismisses their current emotional state and fails to address their immediate concerns about pain. Addressing anxiety proactively fosters trust and ensures the client feels heard and supported before proceeding with the procedure. Delaying the conversation can increase the client's anxiety levels.

Choice B rationale

While the provider may administer a sedative, this statement doesn't fully address the client's anxiety about potential pain. It provides information about medication but doesn't offer reassurance or acknowledge the client's feelings. A more comprehensive approach would involve both medication and supportive communication.

Choice C rationale

Minimizing the client's anxiety by comparing it to the bowel preparation can be dismissive and doesn't validate their feelings about the procedure itself. Each individual experiences procedures differently, and focusing on the discomfort of the preparation might not alleviate their fear of pain during the colonoscopy.

Choice D rationale

Acknowledging the client's anxiety validates their feelings and establishes a supportive nurse-client relationship. Reassuring the client that measures will be taken to ensure their comfort directly addresses their concern about pain. This approach promotes trust and can help reduce the client's anxiety about the procedure.

Choice A rationale

Nausea and vomiting are common side effects of morphine sulfate, an opioid analgesic administered via a PCA pump. An antiemetic medication directly addresses these symptoms and improves patient comfort.

Choice B rationale

Encouraging the use of an incentive spirometer is important for preventing postoperative respiratory complications, but it does not directly address the client's current nausea and vomiting.

Choice C rationale

Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not provide immediate relief from nausea and vomiting. While changes in bowel sounds could indicate a problem, addressing the symptom with an antiemetic is the priority.

Choice D rationale

Inserting a nasogastric tube is an invasive procedure typically reserved for persistent vomiting, bowel obstruction, or gastric decompression. It is not the first-line intervention for nausea and vomiting related to opioid use.