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. Large tumors with distant metastasis may not respond well to radiation therapy, as the effectiveness diminishes when cancer spreads beyond the primary site.
B. While radiation can be effective for superficial cancers, it is most impactful when the cancer is localized.
C. Radiation therapy is most effective for localized cancers, where the treatment can target the tumor directly without affecting surrounding healthy tissues extensively.
D. Cancer spread to multiple sites in one organ complicates treatment and may reduce the efficacy of radiation therapy, as multiple targets may require different approaches.

A. Measure abdominal girth. B. Continue to monitor the drainage. C. Notify the physician. D. Irrigate the nasogastric tube.

Correct Answer is B

Explanation

A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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