Which assessment by a nurse caring for an immediate postoperative patient with an ileal conduit should be reported or receive attention immediately?
a. Lack of bowel sounds
b. Distended abdomen
c. Mucus present in the urine
d. Small amount of blood in the drainage
B
The distended abdomen suggests that the gastrointestinal suction is not effective to prevent bo-wel distention. The nurse must check the efficiency of the suction. Lack of bowel sounds, mucus in the urine, and a small amount of blood in the drainage is to be expected as normal postopera-tive assessments.
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The nurse recognizes that the rehabilitation process involves the efforts of various disciplines. The focus of rehabilitation is to build on which area?
a. A person's losses b. A person's long-term plans c. A person's drives d. A person's abilities
A client tells the nurse that she wants to be checked for a bowel infection because she has been constipated. The nurse should instruct this client that constipation is NOT caused by:
a. low-fiber diet. c. diverticular disease. b. dehydration. d. infectious agents.
The midwife performs a vaginal exam and determines that the fetal head is at a ?2 station. As the nurse, you know that birth:
1. Is imminent. 2. Is likely to occur in 1–2 hours. 3. Will occur later in the shift. 4. Is difficult to predict.
A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse?
a. Decreased level of consciousness b. Tachycardia c. Increased temperature d. Slowed respiratory rate