The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:
no bowel sounds noted during the assessment.
an SPO2 which registers 90% while the client is asleep.
increasing abdominal distention.
a small amount of green-tinged fluid from the nasogastric tube.
The Correct Answer is C
A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.
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C. Decreasing the use of a tanning bed to twice a month still poses a significant risk for skin damage and cancer, as tanning beds expose the skin to high levels of UV radiation. This statement indicates a lack of understanding of the dangers associated with artificial tanning.
D. Wearing a hat and sunglasses while in the sun is an effective strategy for minimizing sun exposure to sensitive areas, protecting the skin and eyes from UV rays, indicating proper sun safety practices.
Correct Answer is C
Explanation
A. The absence of bowel sounds shortly after surgery is a common finding and does not necessarily indicate a complication at this time; it is expected during the initial postoperative period.
B. An SPO2 of 90% while the client is asleep is concerning, but it does not take precedence over signs of possible surgical complications that could require immediate intervention.
C. Increasing abdominal distention is a critical sign that could indicate serious complications such as an anastomotic leak, bowel obstruction, or intra-abdominal bleeding, and it requires immediate notification of the surgeon for further evaluation and potential intervention.
D. A small amount of green-tinged fluid from the nasogastric tube is typical postoperatively and does not necessitate immediate notification to the surgeon unless the volume is excessive or other concerning signs are present.