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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Correct answer: D

A. "Use mineral oil to relieve constipation.": Mineral oil is not recommended during pregnancy because it can interfere with the absorption of fat-soluble vitamins (A, D, E, K).

B. "Drink 1 liter of water daily to decrease constipation.": While hydration is important, 1 liter of water is insufficient. Pregnant clients are advised to drink more, typically around 2-3 liters daily, to help with digestion and prevent constipation.

C. "Use an enema when constipation occurs.": Enemas are generally not recommended during pregnancy without consulting a healthcare provider, as they may stimulate uterine contractions.

D. “Eat an apple to help with constipation.”Apples are high in fiber, which helps to promote bowel regularity and prevent constipation, making them a healthy option for managing constipation during pregnancy.

A. Instruct the client to tilt her head back when she swallows. B. Place food on the left side of the client’s mouth. C. Add thickener to fluids. D. Serve food at room temperature.

Correct Answer is C

Explanation

A. Instruct the client to tilt her head back when she swallows.

Tipping the head back during swallowing is not recommended, especially for individuals with dysphagia. It can increase the risk of aspiration, as it may interfere with the normal swallowing mechanism. The head should be kept in a neutral position during swallowing.

B. Place food on the left side of the client’s mouth.

Placing food on the side with weakness may lead to difficulty in chewing and increased risk of aspiration. The placement of food should be based on the individual's ability and preference, and it's important to consider the safety of swallowing.

C. Add thickener to fluids.

This is the correct choice. Adding thickener to fluids can help modify their consistency, making them easier to swallow and reducing the risk of aspiration. The appropriate thickness should be determined based on the individual's ability to swallow safely.

D. Serve food at room temperature.

While serving food at room temperature may be a preference for some individuals, it is not specifically addressing the safety concerns related to dysphagia and left-sided weakness. The focus should be on modifying food textures and consistencies to ensure safe swallowing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about management of constipation during pregnancy with a group of pregnant clients who are pregnant. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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