A nurse is assessing a client who is 4 hr postoperative following an open appendectomy. Which of the following manifestations should indicate to the nurse that the client requires a nasogastric tube with low intermittent suction?
Decreased oxygen saturation
Abdominal distention
Decreased bowel sounds
Incisional pain
The Correct Answer is B
Rationale:
A. This option is incorrect because decreased oxygen saturation reflects a respiratory problem, such as hypoventilation, atelectasis, or pneumonia, rather than an issue with gastrointestinal function. While low oxygen saturation is clinically significant and requires intervention, it does not indicate a need for nasogastric (NG) tube insertion.
B. This option is correct because abdominal distention after an open appendectomy is a common sign of postoperative ileus or gastric outlet obstruction, both of which can lead to accumulation of gas and fluid in the stomach and intestines. A nasogastric tube with low intermittent suction can decompress the stomach, reduce pressure and discomfort, prevent nausea and vomiting, and lower the risk of complications such as aspiration or wound dehiscence. Early recognition and intervention are essential for client safety and comfort.
C. This option is incorrect because decreased bowel sounds are expected in the first several hours after abdominal surgery due to anesthesia and handling of the intestines. While it signals the need for continued monitoring, it alone does not require NG tube placement. Clinical decisions should consider the combination of symptoms, such as distention, nausea, vomiting, and pain.
D. This option is incorrect because incisional pain is an expected postoperative finding and is managed with analgesics, positioning, and non-pharmacological methods. Pain alone does not indicate gastrointestinal obstruction or the need for NG suction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B","dropdown-group-3":"C"}
Explanation
Rationale for Correct Answers
- Termination of employment: The nurse was already counseled three months ago regarding HIPAA and workstation security. This new incident is a repeat violation of privacy standards, which is usually grounds for immediate dismissal in most healthcare facilities.
- Reprimand from the state board of nursing: State boards oversee professional licenses. Posting client information or derogatory comments about patients on social media violates the Nurse Practice Act and professional boundaries, leading to disciplinary action against their license.
- Criminal penalties: HIPAA violations (especially those involving the disclosure of Protected Health Information on social media) can lead to federal criminal charges, including fines and potential jail time, depending on the severity and intent.
Rationale for Incorrect Choices
- Deletion of social media account: While the nurse might choose to do this, it is not a formal legal or professional disciplinary action imposed by the employer or the state.
- Review by the ethics committee: Ethics committees generally consult on clinical dilemmas (like end-of-life care); disciplinary actions for privacy breaches are handled by Human Resources and Legal departments.
Correct Answer is A
Explanation
Rationale:
A. This option is correct because posting a picture that includes the client assignment board can reveal confidential client information, even indirectly, and constitutes a breach of confidentiality under HIPAA regulations. Sharing any images or information that could identify clients or expose protected health information on social media is inappropriate.
B. This option is incorrect because posting a video of a staff member dancing in the surgical suite after clients have been moved does not involve client information. While it may be unprofessional, it is not a breach of patient confidentiality.
C. This option is incorrect because posting a statement about staffing issues at a previous workplace does not disclose any current client information. Although it could be considered unprofessional or defamatory, it does not violate confidentiality.
D. This option is incorrect because blogging about a provider under investigation does not involve patient information. It could pose legal or professional risks, but it is not a breach of client confidentiality.
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