Fundamentals Question #34

Question

A client in the postanesthesia care unit after surgery begins to vomit. Which action should the nurse make a priority?

Answers

  1. Place the client in a side lying position
    • Rationale:
  2. Encourage the client to take sips of ginger ale
    • Rationale:
  3. Ambulate the client to the bathroom
    • Rationale:
  4. Provide frequent oral hygiene
    • Rationale:

Overview

Explanation

The correct option is A. Placing the client in a side lying position while vomiting will decrease the risk of aspiration and would be the priority. At the time of vomiting the client cannot sip any fluids. Ambulating to the bathroom is contraindicated in the early postoperative period. At the time of vomiting oral hygiene would not be a priority. After the client stops vomiting it can be done to remove residual acid from the vomitus.

Learning Outcomes

Test Taking Tip

Video Rationale