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The nurse is caring for the client who has a temporary colostomy following surgery for colon cancer. The nurse assesses that the client’s colostomy bag is empty and that there has been no stool since surgery 24 hours ago. What should the nurse do?
- A. Call the surgeon immediately.
- B. Place the client left side-lying.
- C. Document these findings.
- D. Give a laxative medication.
Correct Answer: C
Rationale: The nurse should document the findings; the absence of stool is expected 24 hours postsurgery.
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The nurse is caring for the client diagnosed with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the health-care provider?
- A. A decrease in the client's daily weight of one (1) pound.
- B. An increase in urine output after administration of a diuretic.
- C. An increase in abdominal girth of two (2) inches.
- D. A decrease in the serum direct bilirubin to 0.6 mg/dL.
Correct Answer: C
Rationale: An increase in abdominal girth (2 inches) suggests worsening ascites, requiring HCP notification. Weight loss, increased urine output, and normal bilirubin are expected or less urgent.
The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6°F. Which intervention should the nurse implement first?
- A. Notify the health-care provider.
- B. Document the findings in the chart.
- C. Administer an oral antipyretic.
- D. Assess the client's abdomen.
Correct Answer: D
Rationale: Assessing the abdomen first provides critical data on tenderness, rigidity, or rebound, which could indicate complications like perforation, guiding further actions. Notification or medication follows assessment.
The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement?
- A. Weigh the client daily and document in the client's chart.
- B. Teach coping strategies such as dietary modifications.
- C. Record the frequency, amount, and color of stools.
- D. Monitor the client's oral fluid intake every shift.
Correct Answer: C
Rationale: Recording stool frequency, amount, and color is critical in acute IBD exacerbation to assess disease activity and guide treatment. Weight and fluid monitoring are important but secondary, and teaching is less urgent during an acute phase.
The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately?
- A. A serum sodium of 128 mEq/L in a client diagnosed with obstipation.
- B. The client diagnosed with fecal impaction who had two (2) hard formed stools.
- C. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea.
- D. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.
Correct Answer: A
Rationale: Hyponatremia (sodium 128 mEq/L) in obstipation risks neurological complications, requiring immediate HCP attention. Formed stools, normal potassium, and moderate diarrhea are less urgent.
Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy?
- A. Clay-colored stools.
- B. Yellow-tinted sclera.
- C. Amber-colored urine.
- D. WGold-colored urine.
- E. Wound approximated.
- F. Abdominal pain.
Correct Answer: A,B,E
Rationale: Clay-colored stools and yellow-tinted sclera indicate possible bile duct obstruction or jaundice, while abdominal pain suggests complications like infection or bile leak, all requiring HCP notification. Amber urine and approximated wounds are less urgent.