Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

Auscultate bowel sounds.

Ambulate the client in the hallway.

Palpate the abdomen.

Measure hourly urine output.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The correct answer is a) because auscultating bowel sounds can help assess for the return of gastrointestinal function and identify potential complications such as ileus, which can cause abdominal pressure and nausea.

Choice B reason: Ambulating the client is important for postoperative recovery but does not directly address the symptoms of abdominal pressure and nausea.

Choice C reason: Palpating the abdomen is also important but should be done after auscultation to avoid altering bowel sounds.

Choice D reason: Measuring urine output is important for monitoring renal function but does not directly address the symptoms of abdominal pressure and nausea.

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Correct Answer is C

Explanation

Choice A reason: Bile-stained emesis indicates an obstruction, but it is not as immediately critical as a distended, hard, and rigid abdomen.

Choice B reason: Clay-colored stool is a sign of bile duct obstruction but is not as urgent as the abdomen findings.

Choice C reason:

The correct answer is c) because a distended, hard, and rigid abdomen suggests peritonitis or a perforated organ, which requires immediate medical intervention.

Choice D reason: Radiating, sharp pain in the right shoulder is common in gallbladder issues but is not as immediately life-threatening as a distended, hard, and rigid abdomen.

A. Decreased weeping of ulcerations in affected areas. B. Reduced pain in eczematous areas. C. Healing with a return to normal skin appearance. D. Hydration of affected dry skin areas.

Correct Answer is D

Explanation

Choice A reason: Decreased weeping of ulcerations is not the primary expected therapeutic response of urea cream.

Choice B reason: Reduced pain is beneficial but not the primary expected response of urea cream.

Choice C reason: Healing with a return to normal skin appearance may occur over time but is not the immediate expected response of urea cream.

Choice D reason:

The correct answer is d) because urea cream helps hydrate and soften dry skin, which is the primary expected therapeutic response for managing eczema.

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Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?