The nurse receives physician orders for a client who has a suspected small bowel obstruction. Which order(s) should be followed? (SELECT ALL THAT APPLY)
Measure abdominal girth every shift.
Diet: Soft.
0.9% NSS 1000 mL at 125 mL/hr.
Morphine 1 mg IV every 4 hours as needed for abdominal pain.
Correct Answer : A,C,D
Choice A rationale
Measuring abdominal girth every shift helps monitor for increased abdominal distension, which can indicate worsening bowel obstruction or potential complications such as bowel perforation or ischemia. Regular monitoring is crucial to detect changes early.
Choice B rationale
A soft diet is inappropriate for someone with a suspected bowel obstruction, as solid foods can exacerbate the blockage. The standard recommendation is usually to keep the patient NPO (nothing by mouth) to prevent further obstruction.
Choice C rationale
Administering 0.9% NSS at 125 mL/hr helps maintain adequate hydration and electrolyte balance, which is vital in a patient with a bowel obstruction who cannot take oral fluids. This intervention prevents dehydration and electrolyte imbalances.
Choice D rationale
Morphine for pain management is appropriate as it helps alleviate severe abdominal pain associated with bowel obstruction. However, its use should be monitored carefully, as opioids can reduce gastrointestinal motility and potentially worsen the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring for the return of the client's gag reflex is important post-anesthesia, but it is not the priority intervention following an open cholecystectomy. The focus should be on respiratory function and preventing complications.
Choice B rationale
Deep breathing exercises are a priority nursing intervention following an open cholecystectomy to prevent pulmonary complications such as atelectasis and pneumonia. Ensuring proper lung expansion and oxygenation is crucial.
Choice C rationale
Ambulating the client is important for preventing complications such as deep vein thrombosis, but it is not the immediate priority. Early mobilization should be encouraged as soon as the patient is stable and can tolerate it.
Choice D rationale
Discussing dietary restrictions and menu choices is important for long-term recovery and prevention of further gallbladder issues, but it is not the immediate priority after surgery. Postoperative respiratory management takes precedence.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
A triple lumen subclavian catheter provides a reliable, large-bore central line for infusing TPN, ensuring safe and efficient nutrient delivery to meet metabolic needs.
Choice B rationale
A double lumen PICC line inserted above the antecubital fossa is suitable for TPN infusion, providing central venous access with reduced infection risk compared to peripheral lines.
Choice C rationale
A nasogastric tube is used for feeding into the stomach or intestine, not for TPN, which requires central venous access to avoid phlebitis and ensure adequate nutrient delivery.
Choice D rationale
A 22-gauge peripheral IV is not appropriate for TPN, as peripheral lines are more prone to phlebitis and cannot support the high osmolarity of TPN solutions.
Choice E rationale
An 18-gauge peripheral IV is better than a 22-gauge, but peripheral lines in general are not ideal for TPN due to risks like phlebitis and inadequate nutrient delivery.
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