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    RN Adult Medical Surgical 2023 Proctored Exam
    Select All That Apply

    A nurse is caring for a female client following abdominal surgery. Which of the following should the nurse reassess to evaluate the effectiveness of interventions? Select all that apply.

    Explanation & Rationale

    A. Temperature: The client’s temperature is stable and within normal postoperative limits, and there are no signs in the assessment suggesting fever or infection as the primary concern. Reassessing temperature does not directly evaluate the effectiveness of interventions related to abdominal distention, pain, or bowel function. B. Hematocrit: The hematocrit value is mildly low but expected after surgery and shows no indication of acute bleeding or fluid imbalance requiring reevaluation. Monitoring hematocrit will not provide information about the effectiveness of interventions for abdominal symptoms or pain management on postoperative day 3. C. Urine output: The output is currently high (66.7\ mL/hr). While continuous monitoring is always necessary, the primary focus of re-evaluation after intervening for the GI issue is not the urine output. D. Abdomen: The client has abdominal distention, hypoactive bowel sounds, and ongoing severe pain, indicating possible ileus or obstruction. Reassessing the abdomen allows the nurse to evaluate whether interventions are improving bowel motility and reducing gastrointestinal distress. E. Pain rating: The client continues to experience severe pain despite medication, suggesting limited response to current interventions. Reassessing pain helps determine whether additional or alternative pain management measures are required and whether abdominal pathology is worsening. F. Flatus: The presence or absence of flatus is a key indicator of returning bowel function following abdominal surgery. Reassessing flatus helps evaluate whether interventions are improving gastrointestinal motility and reducing the risk of postoperative ileus or obstruction. G. Oxygen saturation: The client’s oxygen saturation is stable, and no respiratory issues are noted in the assessment. Reassessing oxygen saturation does not provide meaningful information about the effectiveness of interventions focused on abdominal symptoms and pain.

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