In caring for a client who is vomiting fecal material, the nurse should place the highest priority on which action?
a. Administering parenteral fluids that contain electrolytes
b. Encouraging the client to take small sips of water
c. Giving the client frequent oral hygiene
d. Preparing the client for surgery
A
This client probably has a small bowel obstruction. In the client with small bowel obstruction, the nurse should maintain good fluid balance by carefully replacing fluid and electrolytes and should administer parenteral fluids, adding sodium chloride, bicarbonate, and potassium as ordered. The priority nursing diagnosis is Deficient Fluid Volume. The client should be maintained on bowel rest (NPO). Surgery is a last resort if decompression does not relieve the obstruction. Frequent oral hygiene is certainly indicated for this client, but is not as high a priority as maintaining fluid and electrolyte balance.
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