A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?
Abdominal distention
Watery stool
Dizziness
Oliguria
The Correct Answer is A
A. Abdominal distention: Abdominal distention is a classic sign of paralytic ileus, which is a temporary cessation of intestinal peristalsis. When peristalsis is impaired, gas and fluid accumulate in the intestines, leading to abdominal distention.
B. Watery stool: Watery stool is not typically associated with paralytic ileus. In paralytic ileus, bowel movements are usually absent or significantly reduced due to decreased or absent peristalsis, resulting in constipation rather than watery stool.
C. Dizziness: Dizziness is not a typical sign of paralytic ileus. While the underlying cause of paralytic ileus may lead to electrolyte imbalances, which can manifest as dizziness, it is not a direct symptom of paralytic ileus itself.
D. Oliguria: Oliguria, or decreased urine output, is not directly related to paralytic ileus. Paralytic ileus affects the gastrointestinal tract, leading to symptoms such as abdominal distention and constipation, but it does not directly affect urinary output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B
Rationale:
A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.
B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.
C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.
D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.
Correct Answer is C
Explanation
A. Peanut butter: Peanut butter is typically thick and sticky, which can pose a choking hazard for individuals with dysphagia, especially if they have difficulty swallowing thicker textures. Therefore, peanut butter is not a suitable recommendation for a client with dysphagia.
B. Crispy rice bar: Crispy rice bars are often dry and crunchy, which can be challenging for individuals with dysphagia to swallow safely. Foods with dry or brittle textures can increase the risk of aspiration or choking, particularly in those with swallowing difficulties.
C. Scrambled eggs: Scrambled eggs are a suitable option for individuals with dysphagia, especially if they are prepared to a soft and moist consistency. Eggs are a good source of protein and can be easily modified to meet the texture requirements of a dysphagia diet. Soft and moist foods are generally safer for individuals with swallowing difficulties.
D. Soda crackers: Soda crackers are dry and crumbly, which can present a choking risk for individuals with dysphagia. Foods with a dry and crumbly texture should be avoided or modified to a safer consistency for individuals with swallowing difficulties. Therefore, soda crackers are not recommended for a client with dysphagia.
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