Difficulty: Medium
Average Score: 69%
Simulated
The client is two (2) hours post colonoscopy. Which assessment data warrant immediate intervention by the nurse?
Correct answer
D
Rationale
Tachycardia (pulse 104) and low BP (98/60) suggest possible bleeding or hypovolemia post-colonoscopy, requiring immediate intervention. A soft abdomen, watery stool, and hyperactive bowel sounds are expected.