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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason:
The correct answer is a) because checking the skin condition of the lower extremities helps identify complications like diabetic ulcers.
Choice B reason:
The correct answer is b) because assessing sensation in feet and legs helps detect neuropathy, a common complication of diabetes.
Choice C reason:
The correct answer is c) because visual acuity checks help identify diabetic retinopathy.
Choice D reason: Signs of respiratory tract infection are important but not specific to long-term complications of diabetes.
Choice E reason:
The correct answer is e) because serum creatinine and BUN levels help assess kidney function and identify nephropathy.
Correct Answer is C
Explanation
Choice A reason: Altered tissue perfusion is important but not the primary concern in osteomalacia.
Choice B reason: Sleep pattern disturbance may occur but is not the highest priority.
Choice C reason:
The correct answer is c) because clients with osteomalacia have weakened bones and are at high risk for fractures, making injury prevention the highest priority.
Choice D reason: Risk of infection is important but not the primary concern in osteomalacia.
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