A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

The coping ability of the client

The client's bowel sounds

The patency of the NG tube

The surgical dressing

Answer and Explanation

The Correct Answer is C

Choice A reason:
Assessing the coping ability of the client is important, but it is not the immediate priority following abdominal surgery. The nurse must first ensure that the client's physiological needs are met and that there are no immediate postoperative complications.

Choice B reason:
While monitoring bowel sounds can provide valuable information about the return of gastrointestinal function, it is not the most immediate concern postoperatively. The nurse should prioritize assessments that ensure the client's safety and immediate physiological stability.

Choice C reason:
Ensuring the patency of the NG tube is the priority assessment. A patent NG tube is crucial for decompressing the stomach, preventing nausea and vomiting, and reducing the risk of aspiration, which can be life-threatening. It is also essential for the removal of gastric secretions and to prevent abdominal distention, which can compromise the surgical site and lead to complications such as wound dehiscence.

Choice D reason:
Assessing the surgical dressing is important to check for signs of bleeding or infection. However, the patency of the NG tube takes precedence as it is directly related to the client's airway and breathing, which are always the top priorities in postoperative care.

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Correct Answer is A

Explanation

Choice A reason:
Morphine is an opioid analgesic that can cause a decrease in gastrointestinal motility, leading to constipation and exacerbation of paralytic ileus, a condition where there is a cessation of peristalsis in the intestine. In the case of paralytic ileus, the intestinal contents cannot move, which can lead to bowel distention, pain, and further complications. Therefore, morphine is contraindicated in clients with paralytic ileus due to the risk of worsening the condition..

Choice B reason:
While morphine can suppress cough and provide some relief in respiratory conditions, it is not contraindicated in bronchitis pleurisy unless respiratory depression is present. However, caution is advised as morphine can cause respiratory depression and should be used carefully in patients with underlying respiratory disorders.

Choice C reason:
Morphine is often used in the management of acute myocardial infarction (MI) to relieve chest pain, reduce anxiety, and decrease the workload on the heart by lowering blood pressure and heart rate. It is not contraindicated in MI; in fact, it can be beneficial in managing the symptoms associated with MI.

Choice D reason:
Postoperative pain management following hip arthroplasty often includes opioids like morphine. Morphine is not contraindicated in this situation and can be used to control postoperative pain, provided that the patient's respiratory function is closely monitored

A. Positive Trousseau's sign B. Cool extremities C. Decreased radial pulse D. Positive Phalen's sign

Correct Answer is D

Explanation

Choice A reason: Positive Trousseau's sign
Trousseau's sign is indicative of hypocalcemia, not CTS. It is elicited by inflating a blood pressure cuff on the upper arm to above systolic pressure for 3 minutes. A positive sign is characterized by carpal spasm, which is not related to CTS.

Choice B reason: Cool extremities
Cool extremities can be a result of various conditions, including peripheral vascular disease or hypothyroidism. They are not a specific indicator of CTS, which primarily affects nerve function rather than blood circulation or temperature regulation.

Choice C reason: Decreased radial pulse
A decreased radial pulse is not typically associated with CTS. It may indicate a cardiovascular issue or a blockage in the radial artery, which would require further investigation unrelated to CTS.

Choice D reason: Positive Phalen's sign
Phalen's sign is a diagnostic test for CTS. The test is performed by having the patient flex their wrist maximally and hold the position for about 60 seconds. A positive Phalen's sign, which includes numbness and tingling in the thumb, index finger, middle finger, and the radial half of the ring finger, is indicative of CTS. This occurs due to increased pressure on the median nerve when the wrist is in flexion.

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A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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