A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

High-pitched bowel sounds

Abdominal bruit

Bruising on the flank area

Coffee-ground emesis

Answer and Explanation

The Correct Answer is A

A) High-pitched bowel sounds: High-pitched bowel sounds, also known as "tinkling" sounds, are characteristic of mechanical bowel obstructions. These sounds are created by the intestines as they try to move contents past the obstruction, resulting in increased peristaltic activity. In the case of intussusception, where one segment of the intestine telescopes into another, the obstruction can cause these distinctive high-pitched sounds due to the narrowing of the bowel lumen.

B) Abdominal bruit: An abdominal bruit is a swishing sound heard over the abdomen, usually indicating turbulent blood flow through narrowed arteries. It is commonly associated with vascular conditions such as atherosclerosis or renal artery stenosis. It is not related to bowel obstruction, as bowel sounds in obstruction cases are generally due to changes in peristaltic activity rather than blood flow.

C) Bruising on the flank area: Bruising on the flank area, known as Grey Turner's sign, is typically seen in conditions involving retroperitoneal hemorrhage, such as severe pancreatitis or trauma. It is not a symptom of bowel obstruction. Bowel obstruction symptoms generally relate to the gastrointestinal tract and include abdominal pain, distension, and altered bowel sounds.

D) Coffee-ground emesis: Coffee-ground emesis is vomit that appears like coffee grounds, indicating the presence of partially digested blood. This is a sign of upper gastrointestinal bleeding, often due to peptic ulcers or gastritis. In mechanical bowel obstruction, vomiting is more likely to contain bile (bilious vomiting) and may occur if the obstruction is high in the small intestine. The appearance of coffee-ground emesis is not typical for bowel obstructions and indicates a different type of gastrointestinal issue.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Provide instruction on pelvic muscle exercises:
Pelvic muscle exercises are beneficial for urinary incontinence but are not a standard intervention for treating pyelonephritis. Pyelonephritis focuses on managing infection and inflammation of the kidneys rather than strengthening pelvic muscles.

B) Administer skeletal muscle relaxants every 6 hr:
Skeletal muscle relaxants are not typically used in the treatment of pyelonephritis. The focus should be on antibiotics to treat the infection and analgesics for pain relief, rather than muscle relaxants.

C) Encourage fluid intake:
Increasing fluid intake helps flush bacteria from the urinary tract, which can aid in reducing the infection and promoting kidney health. Proper hydration is crucial for clients with pyelonephritis to help manage symptoms and prevent further complications.

D) Monitor vital signs every 8 hr:
While monitoring vital signs is important, it should be done more frequently than every 8 hours, especially in the acute phase of pyelonephritis, to promptly identify any signs of worsening infection or sepsis.

A. Give a 25-mg test dose of the medication. B. Flush the IV site with 3 mL of heparin following infusion. C. Instruct the client to remain supine for 10 min after administration. D. Dilute the medication in sterile water for injection.

Correct Answer is D

Explanation

A) Drowsiness: While drowsiness can be a sign of elevated magnesium levels, it is less critical compared to more immediate symptoms like bradycardia. Monitoring and managing drowsiness is important, but bradycardia poses a more immediate risk of severe cardiovascular issues.

B) Diminished patellar reflexes: Diminished reflexes can indicate elevated magnesium levels, but this finding is less urgent compared to symptoms directly affecting heart function. It still needs to be reported but is not the highest priority.

C) Generalized muscle weakness: Muscle weakness is another common sign of high magnesium levels, reflecting the effect of magnesium on neuromuscular function. However, it is less critical compared to bradycardia, which can be life-threatening.

D) Bradycardia: Elevated magnesium levels can significantly impact cardiac function, leading to bradycardia. Bradycardia can be life-threatening, as it may result in decreased cardiac output and potential for severe complications. Therefore, this finding requires immediate attention and should be reported to the provider first.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has pyelonephritis. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is planning to administer the first dose of iron dextran intermittent IV bolus for a client who has iron-deficiency anemia. Which of the following interventions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who was an unrestrained passenger in a motor-vehicle crash. The ABG results are as follows: pH 7.32, HCO3 24 mEq/L, PaCO2 48 mm Hg. The nurse should identify the client is experiencing which of the following acid-base imbalances?

A nurse is caring for a client who just had a left long-arm plaster cast applied after experiencing a musculoskeletal trauma. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who has a hearing impairment and a new hearing aid. Which of the following client statements indicates an understanding of the teaching?

A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate to treat benign prostatic hypertrophy. The client has an indwelling urinary catheter. Which of the following findings should the nurse report to the provider immediately?

A nurse is assessing a client who has vision impairment related to acute angle-closure glaucoma. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who is experiencing anxiety. When using clinical decision making, which of the following actions should the nurse take first?

A nurse is providing teaching to a group of expectant parents about risk factors for sudden infant death syndrome. Which of the following risk factors should the nurse include?