Difficulty: Medium
Average Score: 78%
Simulated
The client with a diagnosis of rule-out colon cancer is two (2) hours post-sigmoidoscopy procedure. Which assessment data warrant immediate intervention by the nurse?
Correct answer
D
Rationale
Low BP (96/60) and tachycardia (pulse 108) suggest hypovolemia or bleeding post-sigmoidoscopy, requiring immediate intervention. Hyperactive bowel sounds, eating, and sleepiness are less urgent.