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 B

Explanation

A. While this information might be helpful for general medication management, it is not directly related to the client's risk for osteoporosis.
B. The amount of calcium in the multivitamin is the most crucial follow-up information. For an older adult at risk for osteoporosis, ensuring adequate calcium intake is essential for bone health. Confirming the amount of calcium in the multivitamin helps ensure that the client is receiving enough of this critical nutrient to support bone density and reduce the risk of fractures.
C. This information is not relevant to the client's bone health or risk for osteoporosis.
D. While this information can influence the absorption of certain nutrients, it is not specifically related to calcium absorption or osteoporosis prevention.

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

Correct Answer is D

Explanation

A. The surgical consent form is crucial for ensuring that the client is informed about the procedure and agrees to it. While it's critical for legal and ethical reasons, this issue can often be resolved relatively quickly by having the client sign the form or addressing it with the surgeon.
B. A pulse oximeter reading of 96% indicates that the client's oxygen saturation is within a generally acceptable range (normal is usually 95% to 100%). This reading suggests that the client's oxygen levels are adequate and typically would not require immediate action.
C. The absence of a preoperative chest x-ray report can be significant, especially if the client has underlying respiratory or cardiac conditions. However, the immediate need for action depends on the urgency and the reason the x-ray was ordered.
D. A serum potassium level of 2.8 mEq/L is critically low. The normal reference range is 3.5 to 5 mEq/L. Hypokalemia (low potassium) can lead to severe complications, including cardiac arrhythmias and muscle weakness, which can significantly impact the client's ability to safely undergo surgery. This condition requires immediate attention to correct the electrolyte imbalance before proceeding with the surgical procedure.

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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

An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?

Correct Answer is B

Explanation

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

Correct Answer is D

Explanation

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