Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?
Auscultate bowel sounds.
Ambulate the client in the hallway.
Palpate the abdomen.
Measure hourly urine output.
The Correct Answer is A
Choice A reason:
The correct answer is a) because auscultating bowel sounds can help assess for the return of gastrointestinal function and identify potential complications such as ileus, which can cause abdominal pressure and nausea.
Choice B reason: Ambulating the client is important for postoperative recovery but does not directly address the symptoms of abdominal pressure and nausea.
Choice C reason: Palpating the abdomen is also important but should be done after auscultation to avoid altering bowel sounds.
Choice D reason: Measuring urine output is important for monitoring renal function but does not directly address the symptoms of abdominal pressure and nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The correct answer is a) because a mask-like face in Parkinson's disease can affect the ability to chew and swallow, increasing the risk of aspiration and nutritional deficiencies.
Choice B reason: Assessing speech patterns is important but secondary to ensuring the client can chew and swallow safely.
Choice C reason: Noting the frequency of drooling can indicate difficulties with swallowing, but determining the ability to chew and swallow is more critical.
Choice D reason: Observing the appearance of the oral mucosa is important for overall oral health but does not address the immediate risk of aspiration and nutritional concerns.
Correct Answer is C
Explanation
Choice A reason: Platelet count is important for clotting but does not directly address the cause of fatigue in pernicious anemia.
Choice B reason: Liver enzymes are important for liver function but are not related to pernicious anemia.
Choice C reason:
The correct answer is c) because a complete blood count (CBC) provides information about hemoglobin and hematocrit levels, which are directly impacted by pernicious anemia and can explain the fatigue.
Choice D reason: Serum electrolytes are important but do not directly address the cause of fatigue in pernicious anemia.
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