A nurse is caring for a client who had a hysterectomy and resumed a regular diet earlier in the day. The client is now reporting nausea and has vomited once. Which of the following actions should the nurse take first?

Check the client's pain level

Assess for bowel sounds and ask the client if she has passed any flatus

Put the client on a clear liquid diet

Administer an antiemetic

Answer and Explanation

The Correct Answer is B

Rationale:
A. While pain assessment is important, nausea and vomiting post-hysterectomy may indicate gastrointestinal issues that need immediate evaluation.
B. Assessing bowel sounds and asking about flatus helps determine if the gastrointestinal tract is functioning properly, which is critical before advancing diet or administering medications. This should be the first action.
C. Changing the diet to clear liquids may be appropriate but only after assessing GI status.
D. Administering an antiemetic can help symptoms but should follow assessment to rule out underlying issues such as ileus or obstruction.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:
A. Capillary refill less than 2 seconds indicates normal peripheral perfusion and is not a cause for concern.
B. A small amount of bloody drainage may be expected initially after injury or surgery, but it should be monitored, not necessarily reported immediately.
C. Some stiffness in the fingers is common after immobilization but does not usually require urgent attention unless it progresses or is accompanied by other symptoms.
D. Increasing pain that is unrelieved by analgesics may be a sign of compartment syndrome, a serious complication of casting that can lead to permanent damage. This is a medical emergency and must be reported immediately.

A. Communicate the findings to the healthcare provider because the client may have a complication, such as an anastomotic leak. B. Slow the client's oral intake in consultation with the dietitian to prevent further dumping syndrome. C. Insert a nasogastric tube as prescribed to facilitate STAT gastric decompression D. Continue to monitor the client.

Correct Answer is A

Explanation

Rationale:
A. Increasing abdominal pain, tachycardia, and a low-grade fever in a postoperative bariatric surgery client may indicate a serious complication such as an anastomotic leak. This requires immediate communication with the healthcare provider.
B. Dumping syndrome typically causes symptoms like dizziness, diarrhea, and sweating after eating—not increasing pain and fever.
C. Nasogastric tube insertion is usually contraindicated after bariatric surgery unless specifically ordered, as it may disrupt surgical sites.
D. These are not mild findings that warrant passive monitoring; prompt intervention is necessary to prevent worsening of a potentially life-threatening complication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who had a hysterectomy and resumed a regular diet earlier in the day. The client is now reporting nausea and has vomited once. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching self-care to a client with a newly applied cast to the forearm. Which of the following does the nurse instruct the client to notify the practitioner immediately?

Correct Answer is D

Explanation

An adult is postoperative on day 2 following bariatric surgery. The nurse's most recent assessment reveals increasing abdominal pain that the client rates at 8 out of 10, a heart rate of 112 beats per minute, and an oral temperature of 38.1°C (100.6°F). What is the nurse's best action?

Correct Answer is A

Explanation

A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse cannot palpate the client's dorsalis pedis or posterior tibial pulse, and the client's foot is pale. What is the nurse's most appropriate action?

A client is in Buck's traction after fracturing his right hip. Which action should the nurse include in the care plan?

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

The nurse is evaluating the pin sites of a client who has been in skeletal traction for 24 hours. The nurse would be least concerned with which finding?

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

The client diagnosed with osteoarthritis (OA) is prescribed a PO non-steroidal anti-inflammatory (NSAID). Which instruction should the nurse teach the client?