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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition
Urinary Retention
The client's symptoms, including the urge to void, feeling "wet," and the bladder scan showing 600 mL of residual urine, suggest urinary retention. Urinary retention occurs when the bladder does not empty completely or at all, leading to a buildup of urine. This can happen postoperatively due to anesthesia effects, pain, or bladder dysfunction.
Actions to Take
• Request prescription for straight catheter
A straight catheter (intermittent catheterization) is used to drain the bladder and measure the amount of urine collected. It is often preferred over an indwelling catheter in cases of acute urinary retention where temporary relief and assessment of bladder function are needed.
• Insert indwelling urinary catheter
An indwelling urinary catheter might be needed if urinary retention persists and is not relieved by other methods. It allows continuous drainage of urine and can be useful in managing acute or severe cases of urinary retention.
Parameters to Monitor
• Amount of urine output
Monitoring urine output is crucial to evaluate how effectively the bladder is emptying after catheterization or other interventions. This helps in assessing whether the urinary retention is being resolved.
• Residual urine
Checking residual urine with a bladder scanner can help determine how much urine remains in the bladder after voiding. Persistent high residual urine levels would indicate ongoing retention issues that need further intervention.
Correct Answer is C
Explanation
A. This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B. This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C. BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D. While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.
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