The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct Answer: A

Rationale: The correct response is A: Stop the flow of solution temporarily. This is the appropriate action to take first in this situation to prevent further complications. By stopping the flow of the solution, the nurse can assess the client's condition and determine the cause of the abdominal cramping. Repositioning the client (B) or massaging the abdomen (D) may exacerbate the cramping if there is an underlying issue. Removing the irrigation tube (C) without proper assessment could lead to complications. It is essential to prioritize the client's safety and well-being by halting the irrigation process to address any immediate concerns.

Correct Answer: B

Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site. A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period. C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage. D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.

Correct Answer: C

Rationale: The correct answer is C, sweating and pallor, for early signs of dumping syndrome. Dumping syndrome is characterized by rapid emptying of the stomach contents into the small intestine, leading to symptoms like diaphoresis (sweating) and pallor due to vasomotor instability. Abdominal cramping and pain (A) are more commonly associated with gastrointestinal issues, not specific to dumping syndrome. Bradycardia and indigestion (B) are not typical symptoms of dumping syndrome, as it usually presents with tachycardia due to fluid shifts. Double vision and chest pain (D) are not commonly associated with dumping syndrome.

Correct Answer: D

Rationale: The correct answer is D because irrigating the Cantor tube with normal saline solution is inappropriate. Cantor tubes are typically used for gastric decompression or feeding, and irrigating with normal saline can disrupt the balance of electrolytes in the stomach. Choice A is correct as injecting air helps facilitate drainage. Choice B is correct as lubricant aids in tube insertion. Choice C is incorrect as coiling tubing can cause kinks and hinder drainage.

Correct Answer: A

Rationale: The correct answer is A: Profuse vomiting. In small bowel obstruction, the vomitus is typically profuse, as the small bowel is narrower and more distensible than the large bowel. This leads to rapid accumulation of gastric contents resulting in frequent vomiting. Cramping abdominal pain (B) can occur in both small and large bowel obstruction. Abdominal distention (C) is a common symptom in both types of obstruction due to the accumulation of gas and fluid. High-pitched bowel sounds above the obstruction (D) are indicative of partial obstruction and can be present in both small and large bowel obstruction.