A nurse is evaluating preoperative teaching with a client who is to undergo surgery with general anesthesia. Which of the following statements by the client indicates an understanding of the teaching?

Rationale for Correct Choices:
• Client reports abdominal pain as a 9 on a pain scale of 0 to 10: Severe abdominal pain indicates significant underlying pathology. In the presence of vomiting, distention, and altered bowel sounds, it could reflect obstruction, ischemia, or peritonitis, requiring urgent intervention.

• Abdomen is distended and firm: Distention and firmness suggest accumulation of gas or fluid within the abdomen. This is concerning for bowel obstruction or peritonitis, which can compromise circulation and lead to sepsis if untreated.

• Bowel sounds are distant and hypoactive: Diminished bowel sounds point to decreased peristalsis. In a client with abdominal pain and distention, this strongly suggests obstruction or ileus, requiring prompt diagnostic and therapeutic measures.

• Perianal skin is excoriated, and small ulceration is noted: Frequent diarrhea has led to skin breakdown and ulceration. This not only causes pain and discomfort but also increases the risk of secondary infection, requiring local wound care and protection.

• Tenting of skin for 4 seconds is noted: Delayed skin turgor indicates poor hydration status. Given this client’s vomiting, diarrhea, and low oral intake, this is a strong indicator of fluid volume deficit needing IV replacement.

• Temperature 38.7 °C (101.7 °F): Fever signals the presence of infection. With gastrointestinal complaints, this may be due to bacterial gastroenteritis, abscess formation, or other intra-abdominal infection that warrants further evaluation.

• Mucous membranes are dry: Dry mucous membranes reflect fluid volume depletion. This is consistent with the client’s history of poor intake, vomiting, and diarrhea, and further confirms dehydration.

Rationale for Incorrect Choices:

• Skin is warm and dry: Warm, dry skin suggests adequate peripheral perfusion and does not require follow-up compared to more urgent findings like dehydration and abdominal changes.

• Capillary refill is 2 seconds: A refill time under 3 seconds indicates sufficient peripheral circulation. This finding is within normal limits and does not require additional intervention.

• Respiratory rate 20/min: A respiratory rate within the range of 12–20 breaths/min is considered normal for adults. This shows stable respiratory function and does not require follow-up.

A. Witnessing a client's signature for informed consent: Witnessing consent is a legal responsibility, not an advocacy role. The nurse verifies the client’s signature but does not address the client’s needs or ensure their voice is represented in care decisions.

B. Instructing a client about how to apply antiembolic stockings: Teaching a client is part of health promotion and nursing education. While important, it does not represent advocacy since it does not involve speaking up or acting on behalf of the client’s expressed needs.

C. Ensuring that all clients receive equal treatment: Providing equitable care is an ethical obligation for all nurses but does not fully represent advocacy. Advocacy specifically involves acting on a client’s behalf when barriers or unmet needs are identified.

D. Requesting a social services consultation for a client who states they cannot afford their medications: This is advocacy because the nurse is acting on the client’s expressed concern and connecting them to resources that address barriers to care. It ensures the client’s health needs are supported beyond routine clinical interventions.