A nurse is caring for a client who is 16 hr postoperative and is experiencing abdominal gas pains. Which of the following actions should the nurse take?

Encourage the client to use an incentive spirometer.

Assist the client with ambulation.

Provide the client with low-fiber food.

Administer pain medication to the client.

Answer and Explanation

The Correct Answer is B

A. Using an incentive spirometer is important for improving lung function and preventing atelectasis, but it does not directly address abdominal gas pains.

B. Assisting the client with ambulation is the best action to alleviate abdominal gas pains. Walking helps stimulate peristalsis and can promote the passage of gas, reducing discomfort.

C. Low-fiber food is not recommended for managing abdominal gas pains postoperatively. In fact, high-fiber foods can help prevent constipation and promote bowel movement, which is beneficial for relieving gas.

D. Administering pain medication may be appropriate if the client is in significant pain, but addressing the underlying cause of the pain (gas) by encouraging ambulation is more effective for long-term relief.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Hypotension
The client is at risk for hypotension due to significant dehydration from osmotic diuresis caused by hyperglycemia. The low blood pressure of 96/65 mm Hg indicates a trend toward hypovolemia, which could worsen if fluid losses are not corrected.
B. Respiratory alkalosis
This is unlikely, as the client has metabolic acidosis (pH 7.30), a hallmark of DKA. The respiratory rate of 18/min does not indicate hyperventilation typically associated with respiratory alkalosis.
C. Renal failure
Elevated creatinine (1.7 mg/dL) and BUN (21 mg/dL) suggest early signs of impaired renal function, likely due to dehydration. If the hypovolemia is not addressed, the client could develop acute kidney injury.

D. Cardiac arrhythmias
The elevated potassium level (5.5 mEq/L) and potential for electrolyte imbalances, such as hypokalemia during insulin therapy, increase the risk of cardiac arrhythmias. Potassium levels must be closely monitored and managed during treatment.

E. Cerebral edema
Although rare, cerebral edema is a possible complication of diabetic ketoacidosis (DKA), particularly if fluid resuscitation is overly rapid or excessive. This condition can lead to neurological deterioration and requires careful monitoring of fluid therapy.

F. Septic shock
While the client has a history of recent infections (bronchitis and pneumonia), there are no current signs of sepsis or septic shock, such as fever, leukocytosis, or hemodynamic instability.

Correct Answer is "{\"xRanges\":[53.828125,93.828125],\"yRanges\":[164,204]}"

Explanation

A. The stoma from a transverse colon resection with colostomy placement is typically located in the right iliac fossa, which is the lower right quadrant of the abdomen. This is where the transverse colon is most often brought to the surface for colostomy placement. It allows for easier access and drainage postoperatively.

B. The epigastric area, which is located above the umbilicus, is not a typical location for a colostomy stoma. This area is more commonly associated with upper abdominal organs such as the stomach and liver.

C. The left iliac fossa is generally where a descending or sigmoid colostomy would be placed, rather than a transverse colon resection. This location would be expected for colostomies created from the descending colon, not the transverse colon.

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A nurse is caring for a client who is 16 hr postoperative and is experiencing abdominal gas pains. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

Correct Answer is "{\"xRanges\":[53.828125,93.828125],\"yRanges\":[164,204]}"

Explanation

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