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.

Choice A rationale Administering an antiemetic may be necessary, but it is not the first action the nurse should take according to the nursing process. Assessment must always precede intervention. Nausea and vomiting in a postoperative client receiving opioids can be a side effect of the medication or a sign of a more serious complication like a paralytic ileus. The nurse must determine the status of the gastrointestinal system before giving additional medications that could mask underlying clinical symptoms. Choice B rationale Using an incentive spirometer is a vital intervention for preventing atelectasis and pneumonia following major surgery, but it does not address the client's immediate complaint of nausea and vomiting. While deep breathing can sometimes help with mild nausea through relaxation, it is not a diagnostic or primary therapeutic action for gastrointestinal distress. The nurse must focus on the specific symptom reported by the client, which requires an assessment of the abdomen and bowel function. Choice C rationale Auscultating bowel sounds is the priority action because it allows the nurse to assess for gastrointestinal motility. General anesthesia and opioid analgesics like morphine sulfate frequently cause decreased peristalsis or a paralytic ileus. Before intervening, the nurse must determine if the nausea is a direct drug side effect or a result of an obstructed or non-functional bowel. Normal bowel sounds typically range from 5 to 30 per minute. Identifying the presence or absence of sounds guides the plan. Choice D rationale Inserting a nasogastric tube is an invasive procedure that is only performed when there is confirmed gastric distension or a confirmed bowel obstruction. It is not an initial nursing action for a report of nausea. The nurse must first perform a physical assessment, including auscultation and palpation, and consult with the provider. Jumping to such an invasive intervention without assessment violates the principles of conservative and evidence-based nursing care in the immediate postoperative period.