# A client is beginning oral intake after abdominal surgery under an enhanced-recovery plan. For each finding or nursing action, select the best classification.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395648&lang=en  
> language: en  
> subject: Nutrition and Oral Hydration  
> category: BCC

## Question

A client is beginning oral intake after abdominal surgery under an enhanced-recovery plan. For each finding or nursing action, select the best classification.

|  | Supports prescribed progression | Pause intake and assess | Requires revision |
| --- | --- | --- | --- |
| Position the client upright and offer manageable portions of the prescribed diet while noting tolerance |  |  |  |
| Record the amount consumed, oral fluids, urine output, and episodes of emesis |  |  |  |
| Pause intake for persistent vomiting with increasing abdominal distention and reassess the client |  |  |  |
| Pause sips when new coughing and a wet voice occur and assess swallowing and respiratory status |  |  |  |
| Advance immediately to a large unrestricted meal despite ongoing nausea because early feeding is preferred |  |  |  |
| Force oral fluids to meet the shift target while the client continues to vomit |  |  |  |

## Explanation

Current surgical-nutrition guidance supports re-establishing oral feeding as early as clinically appropriate, but intake is individualized to the operation and the client's tolerance. Safe nursing care follows the prescribed progression, uses manageable portions and upright positioning, documents intake and losses, and reassesses symptoms. Persistent vomiting, increasing distention, or coughing and a wet voice with sips require pausing intake and assessing the cause. Early feeding is not permission to force fluids, ignore intolerance, or advance immediately to a large unrestricted meal.

## In-depth explanation

Correct Answer
Support the prescribed diet with upright positioning, manageable portions, and intake-output monitoring. Pause and assess persistent vomiting, increasing distention, or new swallowing and airway cues. Revise plans that force intake or advance rapidly despite intolerance.

Why It Fits
Early oral nutrition can support recovery, but the type of surgery and individual tolerance determine how intake progresses. Safety cues override a rigid schedule.

Clinical Picture
Postoperative nausea, vomiting, distention, and swallowing changes can limit safe intake. Tracking what the client consumes and loses helps the team judge hydration and nutrition rather than assuming that an offered tray was tolerated.

Memory Link
Feed early when appropriate; progress by prescription and tolerance.

NCLEX Rule
A guideline favoring early feeding does not erase assessment. Choose the action that combines nutrition support with symptom monitoring and an explicit stop-and-reassess boundary.

Why the Alternatives Fail
Forcing fluids during repeated emesis increases discomfort and aspiration risk. A large unrestricted meal despite nausea ignores tolerance. Continuing sips with coughing and a wet voice bypasses an immediate swallowing and airway assessment.

Source
1ESPEN Guideline on Clinical Nutrition in Surgery, Update 2025
22026 NCLEX-RN Test Plan

## Clinical scenario

The prescribed diet may advance according to the type of surgery and individual tolerance. The nurse supports early nutrition while monitoring nausea, vomiting, abdominal findings, swallowing safety, intake, output, and hydration rather than forcing a fixed progression.

## Key concepts

- **Postoperative Diet Progression** — Resumption and advancement of oral intake according to the type of surgery, the prescribed recovery pathway, and the client's individual tolerance rather than a fixed schedule for all clients.
- **Oral Intake Tolerance** — The client's ability to consume the prescribed food and fluid without concerning nausea, vomiting, distention, pain, swallowing, or respiratory symptoms.
- **Postoperative Ileus Warning Cues** — Persistent vomiting, increasing abdominal distention, inability to tolerate intake, and delayed gastrointestinal recovery are cues that require assessment; they are interpreted with the operation and the complete clinical picture.

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