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 ["A","B","D","E"]

Explanation

A. Pain control options should be appropriate to the setting because different environments (e.g., home vs. hospital) may require different approaches to pain management, ensuring that the interventions align with the patient's needs and the context.
B. Timely and logical delivery of pain relief interventions is critical for effective pain management. Delays in treatment can lead to unnecessary suffering and complicate the overall management of the patient's condition.
C. Asking about pain only once a shift is insufficient for effective pain management. Pain can fluctuate frequently, especially in a client with cancer, so regular assessment is essential to address pain promptly.
D. Believing that pain is what the client reports it to be is fundamental to effective pain management. Pain is subjective, and clients' experiences and expressions of pain should be taken seriously to guide appropriate interventions.
E. A team approach is often the most effective for pain management, as it allows for a comprehensive plan that integrates multiple perspectives and disciplines, including nursing, medical, and possibly palliative care professionals, ensuring a holistic approach to managing pain.

A. Encourage and assist with use of incentive spirometer every hour while awake B. Assist client out of bed on post-operative day 1 C. Reposition client every four hours while in bed D. Utilize aseptic technique while changing dressing E. Maintain TEDS and SCD's while in bed

Correct Answer is ["A","D","E"]

Explanation

A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.
B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.
C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.
D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.
E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.

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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:

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