An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Palpate all peripheral pulses in the extremities.

Encourage cough and deep breathing exercises.

Complete a focused assessment of the abdomen.

Initiate measurement of fluid intake and output.

Answer and Explanation

The Correct Answer is C

A.   While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B.   These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C.   Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D.   Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

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Correct Answer is C

Explanation

A. A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B. Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C. Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D. “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

A. Stone fragments are collected when straining the client's urine. B. Client denies urinary frequency, urgency, or dysuria. C. Urine is pale pink with no observable blood clots. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Correct Answer is A

Explanation

A. This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B. While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C. Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.

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An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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