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 B
Explanation
Choice A reason: Frequent use of antacids may suggest gastrointestinal issues but is not specific to peptic ulcer disease.
Choice B reason:
The correct answer is b) because upper midabdominal pain described as gnawing and burning is a classic symptom of peptic ulcer disease.
Choice C reason: Marked loss of weight and appetite can be associated with many conditions and is not specific to peptic ulcer disease.
Choice D reason: Severe abdominal cramps and diarrhea after eating spicy foods are not typical symptoms of peptic ulcer disease.
Correct Answer is C
Explanation
Choice A reason: While the chest x-ray report is important, it is not as immediately critical as a low potassium level.
Choice B reason: The surgical consent form is important but can be addressed quickly before surgery.
Choice C reason:
The correct answer is c) because a preoperative serum potassium level of 2.8 mEq/L is dangerously low and requires immediate correction to avoid cardiac complications during surgery.
Choice D reason: A pulse oximeter reading of 96% is within normal limits and does not require immediate action.
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