The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:

no bowel sounds noted during the assessment.

an SPO2 which registers 90% while the client is asleep.

increasing abdominal distention.

a small amount of green-tinged fluid from the nasogastric tube.

Answer and Explanation

The Correct Answer is C

A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.

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Correct Answer is C

Explanation

A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.

A. pick up the implant with gloved hands and place it in bedside container. B. pick up the implant with long handled forceps and place it in a lead container. C. call for the rapid response team. D. call the radiation oncologist immediately.

Correct Answer is B

Explanation

A. Picking up the implant with gloved hands does not ensure safety and proper handling of a radioactive material, as gloves do not provide adequate protection against radiation exposure.
B. Using long-handled forceps to pick up the implant and placing it in a lead container is the correct action, as it minimizes radiation exposure to the nurse and ensures the safe containment of the radioactive source.
C. Calling for the rapid response team is unnecessary in this scenario; the situation requires immediate containment of the radioactive material rather than emergency medical intervention.
D. Calling the radiation oncologist is not the first action; while it is important to inform the physician afterward, the priority is to secure the radioactive implant properly to prevent exposure.

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The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client post-operatively following an open (incisional) cholecystectomy. Which would be the priority nursing intervention for this client?

Correct Answer is C

Explanation

The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to:

Correct Answer is B

Explanation

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