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.

Answer and Explanation

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.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

Withholding food and fluids is essential to prevent complications should surgery be needed.

Choice B rationale

Administering prophylactic IV antibiotics helps prevent infection, which is critical in cases of appendicitis.

Choice C rationale

Applying heat to the abdomen can increase circulation and the risk of rupture in appendicitis.

Choice D rationale

Administering an enema can increase the risk of perforation in appendicitis.

Choice E rationale

Ambulation can exacerbate pain and the risk of rupture in a client with suspected appendicitis.

A. Increase the IV fluid flow rate if the blood pressure is low. B. Listen to the breath sounds in all lung fields. C. Check the abdominal dressing for bleeding. D. Document the amount of output on the I&O sheet.

Correct Answer is D

Explanation

Choice A rationale

Increasing the IV fluid flow rate is a critical task requiring clinical judgment and should not be delegated to an unlicensed nursing assistant. This task involves assessing the patient's hemodynamic status and fluid balance, which requires nursing expertise.

Choice B rationale

Listening to breath sounds in all lung fields is an assessment task that requires nursing knowledge and skills. It involves identifying normal and abnormal breath sounds, which is outside the scope of practice for an unlicensed nursing assistant.

Choice C rationale

Checking the abdominal dressing for bleeding is an assessment and monitoring task. It involves evaluating the wound site for signs of hemorrhage or infection, which requires nursing assessment skills.

Choice D rationale

Documenting the amount of output on the I&O sheet is a task that can be delegated to an unlicensed nursing assistant. This task involves recording measurements, which does not require clinical judgment and is within the assistant's scope of practice.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B"]

Explanation

The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to an unlicensed nursing assistant?

Correct Answer is D

Explanation

The nurse is caring for a client who is 4 hours post-op after an open cholecystectomy. The nurse would expect the client's bowel sounds to be:

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