A nurse is caring for a client who is 24 hours post-hysterectomy. The client is experiencing moderate abdominal pain and is requesting pain medication. The nurse notices the client's urinary output is 45 mL over the past 3 hours. Which of the following is the most appropriate nursing action?

Encourage the client to ambulate and increase fluid intake to stimulate urination

Check the client's bladder for distention and notify the healthcare provider if necessary.

Increase the client's fluid intake and reassess the output in 4 hours.

Administer the prescribed pain medication and document the findings

Answer and Explanation

The Correct Answer is B

Rationale:
A. Encouraging ambulation and fluids may help, but the low urine output (oliguria) over 3 hours warrants assessment of bladder distention first to rule out urinary retention.
B. Checking the bladder for distention is the most appropriate immediate action, as urinary retention is a common postoperative complication that can cause pain and reduced output. The healthcare provider should be notified if retention is present.
C. Increasing fluids alone without assessment may delay necessary intervention.
D. Administering pain medication without assessing the cause of decreased output may mask symptoms and delay diagnosis of urinary retention or other complications.

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Correct Answer is D

Explanation

Rationale:
A. Intact skin around the stoma is a normal and expected finding, indicating proper appliance fit and skin care.
B. A stoma that is moist, pink, and slightly protruding is the desired appearance postoperatively.
C. The presence of gas and liquid stool is expected as bowel function begins to return.
D. A dark purple, dusky, and dry stoma suggests compromised blood flow or necrosis, which is a surgical emergency. This finding requires immediate notification of the healthcare provider.

A. Assess the client for a hypersensitivity reaction B. Evaluate the client for hypercalcemia C. Examine the client for hepatomegaly D. Check the results of the client's most recent CBC

Correct Answer is D

Explanation

Rationale:
A. Hypersensitivity reactions to cisplatin typically involve symptoms like rash, shortness of breath, or facial swelling—not fatigue alone.
B. Hypercalcemia is more commonly associated with cancers like multiple myeloma or bone metastases, and it usually causes confusion, nausea, or constipation—not just fatigue.
C. Hepatomegaly may occur in metastatic disease but is not a routine complication of cisplatin and is less directly linked to fatigue.
D. Fatigue in a client receiving chemotherapy such as cisplatin is commonly due to anemia, a result of bone marrow suppression. Checking the complete blood count (CBC) is essential to assess for decreased red blood cells or other cytopenias.

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A nurse is caring for a client who is 24 hours post-hysterectomy. The client is experiencing moderate abdominal pain and is requesting pain medication. The nurse notices the client's urinary output is 45 mL over the past 3 hours. Which of the following is the most appropriate nursing action?

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The nurse is assessing a client who is 2 days postoperative from a colostomy. Which of the following findings should the nurse report to the healthcare provider immediately?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving cisplatin, a chemotherapy agent, to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

Correct Answer is D

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