The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:

no bowel sounds noted during the assessment.

an SPO2 which registers 90% while the client is asleep.

increasing abdominal distention.

a small amount of green-tinged fluid from the nasogastric tube.

Answer and Explanation

The Correct Answer is C

A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.

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Correct Answer is ["16"]

Explanation

To calculate the volume to be withdrawn from the vial, we need to follow these steps:

Convert the client's weight from pounds to kilograms:
- 110 lbs * (1 kg / 2.2 lbs) = 50 kg
Calculate the total dose of Vancomycin based on the prescribed dosage:
- 20 mg/kg * 50 kg = 1000 mg
Calculate the volume to be withdrawn from the vial:
- 1000 mg * (8 mL / 500 mg) = 16 mL

A. pain control options should be appropriate to the setting. B. delivery of pain relief interventions should be timely and logical. C. asking about pain once a shift. D. belief that pain is what the client reports it is. E. most effective when provided by a team approach.

Correct Answer is ["A","B","D","E"]

Explanation

A. Pain control options should be appropriate to the setting because different environments (e.g., home vs. hospital) may require different approaches to pain management, ensuring that the interventions align with the patient's needs and the context.
B. Timely and logical delivery of pain relief interventions is critical for effective pain management. Delays in treatment can lead to unnecessary suffering and complicate the overall management of the patient's condition.
C. Asking about pain only once a shift is insufficient for effective pain management. Pain can fluctuate frequently, especially in a client with cancer, so regular assessment is essential to address pain promptly.
D. Believing that pain is what the client reports it to be is fundamental to effective pain management. Pain is subjective, and clients' experiences and expressions of pain should be taken seriously to guide appropriate interventions.
E. A team approach is often the most effective for pain management, as it allows for a comprehensive plan that integrates multiple perspectives and disciplines, including nursing, medical, and possibly palliative care professionals, ensuring a holistic approach to managing pain.

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The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A physician prescribes Vancomycin 20 mg/kg IV. The client weighs 110 lbs. The medication is available in vials which contain 500 mg per 8 mL. What should the nurse withdraw from the vial?

Correct Answer is ["16"]

Explanation

The nurse caring for a client diagnosed with pancreatic cancer understands that the key to effective pain management is: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D","E"]

Explanation

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