A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions is the priority for the nurse to take?
Provide an antiemetic.
Make the client NPO.
Administer a stimulant laxative.
Auscultate bowel sounds.
The Correct Answer is D
A. Provide an antiemetic.
While providing an antiemetic can help alleviate the client's nausea and vomiting, it is not the priority action. Assessment should come first to determine the underlying cause.
B. Make the client NPO.
Making the client NPO might be necessary if there is concern about bowel obstruction or other gastrointestinal issues, but this decision should be based on an initial assessment, such as auscultating bowel sounds.
C. Administer a stimulant laxative.
Administering a stimulant laxative is not appropriate at this stage without first assessing bowel sounds. It could potentially worsen the situation if there is a bowel obstruction.
D. Auscultate bowel sounds.
The priority in this situation is to assess for possible complications such as bowel obstruction or paralytic ileus, which can occur postoperatively and can be exacerbated by opioid use. Auscultating bowel sounds helps determine the presence of normal, hypoactive, or absent bowel sounds, guiding further management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “Most of my calories each day should be from fats.”
This statement is not accurate. While fats are essential for a balanced diet, it is not recommended for the majority of calories to come from fats. The emphasis should be on a variety of macronutrients, including carbohydrates and proteins.
B. “I should eat more calories from complex carbohydrates than anything else.”
This is the correct choice. Individuals with diabetes are often encouraged to obtain the majority of their calories from complex carbohydrates. These include whole grains, vegetables, and legumes, which have a slower impact on blood glucose levels.
C. “Simple sugars are needed more than other calorie sources.”
This statement is not accurate for individuals with diabetes. Simple sugars can lead to rapid spikes in blood glucose levels and should be consumed in moderation.
D. “Protein should be my main source of calories.”
This statement is not accurate. While protein is important for overall health, it is not recommended for protein to be the main source of calories. A balanced diet with an emphasis on complex carbohydrates is typically recommended.
Correct Answer is B
Explanation
A. Ensure the rope knots are away from the pulleys.
While ensuring that rope knots are away from the pulleys is a general principle in traction care to maintain proper functioning, it is not directly related to the specific positioning of the child's feet in Buck's traction.
B. Ensure the child’s feet are against the footboard.
This statement is correct. Ensuring that the child's feet are against the footboard helps maintain proper hip alignment and prevent complications such as contractures. It is an important aspect of care when managing Legg-Calve-Perthes disease in Buck's traction.
C. Apply antibiotic ointment to the pin sites daily.
This action is not applicable to Buck's traction. Buck's traction involves the use of a boot or splint, and it does not include pins or pin sites. The use of antibiotic ointment for pin sites is more relevant in the context of skeletal traction.
D. Reduce the child’s fluid intake.
There is no indication to reduce the child's fluid intake specifically in the context of Buck's traction. Adequate hydration is generally important for overall health, and fluid restriction is not a standard practice for managing Legg-Calve-Perthes disease in Buck's traction.
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