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 C

Explanation

A. Assessing pupils is important, but it provides only partial information about the overall neurologic status and does not give a comprehensive picture of improvement or deterioration.
B. Vital signs can indicate some changes in condition but are not specific to neurologic status and do not provide detailed insight into cognitive or motor function.
C. Performing serial Glasgow Coma Scales allows for a standardized and objective assessment of a patient's level of consciousness, motor responses, and verbal responses over time, making it the most effective method to evaluate neurologic status.
D. The Mini Mental Status Exam provides useful information about cognitive function but may not capture acute changes in neurologic status as effectively as the Glasgow Coma Scale.

A. Garden salad B. Applesauce C. Baked potato D. Steamed broccoli

Correct Answer is A

Explanation

A. A garden salad may contain raw vegetables, which can harbor bacteria and pose a risk of infection for a client with neutropenia, making this the concerning choice.
B. Applesauce is typically safe as it is a processed food that has been cooked, reducing the risk of bacterial contamination.
C. A baked potato is also safe as long as it is properly cooked and handled, which minimizes the risk of foodborne illness.
D. Steamed broccoli is safe because the cooking process eliminates harmful bacteria, making it a better choice for someone with neutropenia.

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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:

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