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 A
Explanation
A. Stress incontinence
Stress incontinence is the involuntary loss of urine during activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting heavy objects. In stress incontinence, the pelvic floor muscles are weakened, leading to inadequate support of the bladder and urethra. This results in leakage of urine during moments of increased pressure on the bladder.
B. Urge incontinence
Urge incontinence involves a strong and sudden urge to urinate, leading to involuntary urine loss. It is often associated with an overactive bladder and may not be related to increased abdominal pressure.
C. Overflow incontinence
Overflow incontinence occurs when the bladder is unable to empty completely, leading to constant dribbling of urine. It is often associated with conditions that obstruct urine flow, such as an enlarged prostate in men.
D. Reflex incontinence
Reflex incontinence is characterized by the involuntary loss of urine due to a reflex arc that bypasses normal control mechanisms. It is often associated with neurological conditions that affect bladder control.
Correct Answer is B
Explanation
A. Set the pad’s temperature to 42.2° C (108 F).
The specific temperature setting for a heat application should be based on the healthcare provider's prescription and the therapeutic goals. The temperature should be within a safe and therapeutic range.
B. Stop the treatment if the client’s skin becomes red.
This is the correct choice. Redness on the skin during heat application may indicate potential skin irritation or the onset of a burn. Stopping the treatment if redness occurs is crucial to prevent further injury.
C. Leave the pad in place for at least 40 min.
The duration of heat application should also be based on the healthcare provider's prescription and therapeutic goals. Leaving the pad in place for a specific duration is important, but the exact time would depend on the therapeutic plan.
D. Use safety pins to keep the pad in place.
Safety pins should not be used to secure heat applications, as they can pose a risk of injury. Instead, healthcare professionals should use the appropriate securing devices provided with the heat application or follow facility protocols.
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