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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.
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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.
A nurse cares for a client who has a family history of colon cancer. The client states, 'My father and my brother had colon cancer. What is the chance that I will get cancer?' How should the nurse respond?
- A. If you eat a low-fat and low-fiber diet, your chances decrease significantly.
- B. There's no way to predict your individual risk with certainty.
- C. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer.
- D. You should have a colonoscopy more frequently to identify abnormal polyps early.
Correct Answer: D
Rationale: A family history of colon cancer increases risk, so frequent colonoscopies are recommended to detect abnormal polyps early, improving outcomes through early intervention.
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 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.