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: 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.

A. Bronchoscopy. B. Chest tube insertion. C. Endotracheal intubation. D. Pulmonary function test.

Correct Answer is B

Explanation

Choice A reason: Bronchoscopy is used for visualizing the airways and not for treating a pneumothorax.

Choice B reason:

The correct answer is b) because absent breath sounds on one side and increasing dyspnea suggest a pneumothorax, which requires chest tube insertion to re-expand the lung.

Choice C reason: Endotracheal intubation is for airway management but does not address the underlying pneumothorax.

Choice D reason: Pulmonary function tests are not relevant in an emergency situation with suspected pneumothorax.

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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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Explanation

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