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A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, 'I need to have a bowel movement.' How should the nurse respond?
- A. I will administer a laxative to help you have a bowel movement.
- B. Let's get you to the bathroom to try and have a bowel movement.
- C. It's too soon after surgery; you should wait at least 24 hours.
- D. You should avoid straining; I'll consult with your provider about a stool softener.
Correct Answer: D
Rationale: After a hemorrhoidectomy, straining should be avoided to prevent complications. The nurse should consult with the provider about a stool softener to facilitate a bowel movement without straining.
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A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider?
- A. White blood cell (WBC) count of 1500/mm3
- B. Fatigue
- C. Nausea and diarrhea
- D. Mucositis and oral ulcers
Correct Answer: A
Rationale: A WBC count of 1500/mm3 is significantly below the normal range (5000-10,000/mm3), indicating a high risk for infection. The provider should be notified immediately, as chemotherapy may need to be delayed.
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, 'My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it.' How should the nurse respond?
- A. Your doctor should not have given you that information prior to the colonoscopy.
- B. The colonoscopy is required due to the high percentage of false negatives with the blood test.
- C. A negative fecal occult blood test does not rule out the possibility of colon cancer.
- D. I will contact your doctor so that you can discuss your concerns about the procedure.
Correct Answer: C
Rationale: A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. A colonoscopy is necessary to visualize the entire colon and take a tissue sample for biopsy.
A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?
- A. Have you been experiencing any constipation?
- B. Are you eating a diet high in fiber and fluids?
- C. Do you have a history of high blood pressure?
- D. Have you noticed any changes in your vision?
Correct Answer: A
Rationale: Constipation is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.
A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
- A. Encouraging ambulation three times a day
- B. Encouraging normal urination
- C. Encouraging deep breathing and coughing
- D. Encouraging the client to ambulate
- E. Forcefully reducing the hernia
Correct Answer: A,B,D
Rationale: Postoperative care includes encouraging ambulation and normal urination to promote recovery. Coughing is avoided to prevent strain on the repair, and forceful reduction is not appropriate.
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first?
- A. Measure the client's abdominal girth.
- B. Assess for abdominal guarding or rigidity.
- C. Check the client's hemoglobin and hematocrit.
- D. Obtain the client's complete health history.
Correct Answer: B
Rationale: Ecchymotic areas may indicate internal bleeding or organ injury. The nurse should first assess for abdominal guarding or rigidity, which could indicate a major organ injury, and then notify the provider.