The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?

Question

Quizplus · Accepted Answer

11ecbb05_cbe4_4d24_b433_d158630bbe76_MD0009_00 An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. (Option A) Elevated creatinine is expected in a client scheduled for hemodialysis. The nurse should review the prescribed medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and after dialysis and seek direction from the health care provider if necessary. (Option B) Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants [amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia). Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel. (Option C) The client with excessive yellow, foul-smelling drainage will need a dressing change; however, these findings are expected in a client with an infected venous leg ulcer. Educational objective: Intestinal obstruction and strangulated bowel are life-threatening complications associated with an incarcerated hernia and require immediate evaluation and urgent surgical intervention.

The Nurse Is Planning to Assess 4 Assigned Clients