A nurse is caring for a female client following abdominal surgery. Complete the following sentence by using the lists of options. The nurse should plan to firstdropdown

Rationale for Correct Answer: Raise the head of the bed: This client’s findings are highly suggestive of a postoperative bowel obstruction or paralytic ileus, evidenced by abdominal distention, high-pitched bowel sounds, vomiting of brown liquid, and severe cramping pain unrelieved by opioids. Using ABCs, the priority concern is airway protection. Active vomiting places the client at high risk for aspiration, especially while lying supine. Raising the head of the bed is an immediate, independent nursing action that helps reduce aspiration risk and supports breathing while further evaluation and provider notification occur. Rationale for Incorrect Answers: Obtain a prescription for additional pain medication: This is not appropriate as the first action. Opioids can worsen bowel motility and mask worsening obstruction. Obtain an order to remove the indwelling urinary catheter: Urinary output is adequate (800 mL/12 hr). This is not the priority in an acute abdominal emergency. Review the client’s laboratory results: Labs are important but do not address the immediate safety risk of vomiting and potential aspiration.