Practice Question
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?
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Correct Answer:
Administer an antiemetic.
Rationale:
🟦 Opioids like morphine commonly cause nausea and vomiting by stimulating the chemoreceptor trigger zone and slowing GI motility.
🟦 Giving an ordered antiemetic treats the symptom promptly, improves comfort, and helps prevent aspiration risk in a postoperative client.
🟦 Controlling nausea also supports better pain control, because untreated vomiting can lead clients to avoid using the PCA and then experience uncontrolled pain.
🟦 Post-op nausea can worsen fluid/electrolyte imbalance, so treating it early supports recovery and oral intake tolerance.
🟦 This is the most direct, evidence-based nursing response when nausea/vomiting is linked to opioid analgesia and there is no evidence of bowel obstruction in the stem.
Insert a nasogastric tube.
🟦 An NG tube is not first-line for opioid-related nausea and is typically reserved for bowel obstruction/ileus or severe gastric decompression needs.
🟦The scenario describes expected opioid side effects rather than a GI emergency.
Encourage use of the incentive spirometer.
🟦Incentive spirometry helps prevent atelectasis, but it does not treat nausea and vomiting.
🟦It’s appropriate postoperative care, just not the priority response to the current symptom.
Auscultate bowel sounds.
🟦 Assessing bowel sounds can be helpful overall, but it does not relieve the client’s active nausea/vomiting.
🟦 The immediate need is symptom control to reduce discomfort and prevent aspiration.
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This question is from Custom NUR213 Final Assessment FA II 2025 Assessment 1 which contains 63 questions.
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From Exam
Custom NUR213 Final Assessment FA II 2025 Assessment 1
63 Questions
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- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 4