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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

A. Preoperative chest x-ray report is not available. B. Surgical consent form is not signed. C. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L). D. Client's pulse oximeter reading is 96%.

Correct Answer is C

Explanation

Choice A reason: While the chest x-ray report is important, it is not as immediately critical as a low potassium level.

Choice B reason: The surgical consent form is important but can be addressed quickly before surgery.

Choice C reason:

The correct answer is c) because a preoperative serum potassium level of 2.8 mEq/L is dangerously low and requires immediate correction to avoid cardiac complications during surgery.

Choice D reason: A pulse oximeter reading of 96% is within normal limits and does not require immediate action.

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Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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