The nurse has reviewed the Nurses' Notes from Postoperative day 3 at 0630, For each potential action, click to specify if the action is indicated or not indicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Encourage client to take in oral fluids: The client is currently NPO postoperatively due to vomiting, distended abdomen, absent flatus, and bowel obstruction signs. Encouraging oral intake is not indicated until bowel function returns. Provide frequent mouth care: Because the client is NPO, frequent mouth care is indicated to maintain oral hygiene and comfort. Limit the client's movement in the bed: Early mobilization is generally encouraged to prevent complications such as atelectasis and venous thromboembolism. Limiting movement is not indicated. Obtain a prescription for an antidiarrheal medication: The client has watery stools, but given postoperative status and possible bowel obstruction, giving antidiarrheal medication without provider assessment is not indicated. Obtain a prescription for a blood transfusion: Hemoglobin and hematocrit are slightly low but stable (Hgb 10 g/dL, Hct 34%). There is no evidence of acute bleeding requiring transfusion, so this is not indicated. Prepare for insertion of an NG tube: The client has vomiting, abdominal distention, high-pitched bowel sounds in upper quadrants, absent lower quadrant bowel sounds, and no flatus, all suggesting possible postoperative bowel obstruction. Insertion of an NG tube is indicated to decompress the stomach and relieve symptoms. Prepare to administer enteral nutrition: The client is NPO and has signs of obstruction, so enteral nutrition is not indicated until bowel function returns. Hold pain medications until condition resolves: Pain management is critical, especially postoperative pain. Holding medications is not indicated; however, monitoring for worsening abdominal distention is essential.