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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.
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A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?
- A. Administer intravenous opioid medications.
- B. Position the client with knees to chest.
- C. Insert a nasogastric tube for decompression.
- D. Auscultate the client's bowel sounds.
Correct Answer: D
Rationale: A change from intermittent to constant abdominal pain in a client with a bowel obstruction may signal peritonitis or perforation. The nurse should auscultate for bowel sounds and check for rebound tenderness, then notify the provider.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, 'The stool in my pouch is still liquid.' How should the nurse respond?
- A. The stool will always be liquid with this type of colostomy.
- B. Eating additional fiber will bulk up your stool and decrease diarrhea.
- C. The stool will become firmer over the next couple of weeks.
- D. This is abnormal. I will contact your health care provider.
Correct Answer: A
Rationale: Stool from an ascending colostomy remains liquid because there is little large bowel to reabsorb liquid. This is expected and not abnormal, and neither fiber nor time will change this.
A nurse cares for a client with colon cancer who has a new colostomy. The client states, 'I think it would be helpful to talk with someone who has had a similar experience.' How should the nurse respond?
- A. I have a good friend with a colostomy who would be willing to talk with you.
- B. I will make a referral to the United Ostomy Associations of America.
- C. I will arrange for a visit from an enterostomal therapist.
- D. I can talk with people who have colostomies, but many don't want to share their experiences.
Correct Answer: B
Rationale: The nurse should refer the client to a community-based resource like the United Ostomy Associations of America, where they can connect with others who have similar experiences.
A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take?
- A. Assess the client's heart rate and blood pressure.
- B. Determine when the client last voided.
- C. Ask if the client is experiencing nausea.
- D. Auscultate all quadrants of the client's abdomen.
Correct Answer: B
Rationale: Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience urinary retention. Determining when the client last voided helps confirm this.
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.