A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt?
a. discontinue intravenous therapy
b. Assess for abdominal distension and tenderness
c. Obtain a prescription for a diet change
d. Auscultate bowel sound in all four quadrants
Ans: d. Auscultate bowel sound in all four quadrants
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A client has hypervolemic hyponatremia. The assessment finding the nurse would find inconsistent with this condition is
a. dysrhythmias b. hypotension. c. jugular vein distention. d. S3 gallop.
Mrs. Stethem seems very confused about when to take her medicines, even though the nurse has explained all discharge instructions to her. What should the nursing assistant do?
A. Find out when the medicines are to be taken and explain it again to Mrs. Stethem. B. Tell Mrs. Stethem to call her doctor after she gets home, to clarify when to take the medicines. C. Report to the nurse that Mrs. Stethem is confused about her medicines. D. Say nothing, since the pharmacist will label the bottles with the correct times to take the medicines.
An appropriate technique for the nurse to implement during nasogastric tube insertion is to:
A. Rotate the tube if resistance is felt B. Advance the tube in between swallows C. Start with the client's head flexed D. Check the tube placement by instilling air and auscultating over the stomach