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

None

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. Clients with skin traction have more mobility than those with skeletal traction. B. Clients with skin traction have more discomfort than those with skeletal traction. C. Skeletal traction is more appropriate than skin traction for reducing a fracture. D. Skeletal traction has less risk for infection than skin traction.

Correct Answer is C

Explanation

Choice A reason:

Skin traction is indeed less restrictive than skeletal traction, allowing for more mobility. It is applied using bandages or adhesive material to the skin, which can be removed or adjusted more easily than the pins or screws used in skeletal traction. This type of traction is typically used for short-term treatment before surgery or when the injury is less severe.

Choice B reason:

Discomfort levels can vary depending on the individual and the specific circumstances of the traction. However, skin traction is generally considered to be less painful than skeletal traction because it is less invasive and applies less force. Skeletal traction, which involves the insertion of pins or wires directly into the bone, is likely to cause more discomfort due to the invasive nature of the procedure.

Choice C reason:

Skeletal traction is more appropriate for reducing fractures, especially in cases where a greater force is needed to align the bones. It involves the surgical insertion of pins or wires directly into the bone, allowing for a stronger and more stable pull that is necessary for the realignment of complex fractures.

Choice D reason:

Skeletal traction carries a higher risk of infection compared to skin traction because it is more invasive. The insertion of pins or wires into the bone creates a potential entry point for bacteria, which can lead to infection at the site of insertion.

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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

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

Correct Answer is A

Explanation

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

Correct Answer is C

Explanation

A nurse is caring for a 68-kg (150-lb) client who has dehydration. Which of the following manifestations is an indication of effective treatment?

A nurse is educating a client who has osteoarthritis of the knee. Which of the following explanations should the nurse give to the client as part of the disease process?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include?

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A nurse is teaching a client who has hepatitis A about preventing the transmission of the virus. Which of the following strategies should the nurse include in the teaching?

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?