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

A. Drink carbonated beverages.

Carbonated beverages may cause bloating and gas, which can be uncomfortable for individuals with COPD. It's generally advisable to choose non-carbonated and non-caffeinated beverages.

B. Decrease fiber intake.

Decreasing fiber intake is not a recommended approach for individuals with COPD. Fiber is important for digestive health and overall well-being. A balanced diet, including adequate fiber, is generally encouraged.

C. Use bronchodilators after meals.

The timing of bronchodilator use is typically based on a schedule or as needed for symptom control, rather than being specifically linked to mealtime. It's important to follow the healthcare provider's instructions regarding the use of bronchodilators.

D. Increase protein intake.

Increasing protein intake is an appropriate nutritional recommendation for individuals with COPD. Protein is important for maintaining respiratory muscle strength and overall health.

A. Massage the client’s bony prominences. B. Keep the head of the bed elevated. C. Reposition the client at least every 2 hr. D. Keep the client’s skin moist.

Correct Answer is C

Explanation

A. Massage the client’s bony prominences:

Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.

B. Keep the head of the bed elevated:

While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.

C. Reposition the client at least every 2 hr:

Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.

D. Keep the client’s skin moist:

While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.

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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

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Correct Answer is D

Explanation

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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