A nurse is collecting data from a client who has peritonitis.Which of the following findings should the nurse expect?
Decreased respirations.
Absent bowel sounds.
Peripheral edema.
Polyuria.
The Correct Answer is B
Choice A rationale
Peritonitis usually leads to increased respiratory rate rather than decreased respirations due to abdominal pain and possible sepsis. Rapid breathing is a common symptom as the body tries to compensate for the infection and discomfort.
Choice B rationale
Absent bowel sounds are a hallmark sign of peritonitis, indicating a lack of intestinal activity due to severe inflammation of the peritoneum. This condition can lead to ileus, where the intestines stop functioning properly.
Choice C rationale
Peripheral edema is not typically associated with peritonitis. Peritonitis primarily affects the abdomen and does not commonly cause fluid accumulation in the extremities. Edema is more related to conditions affecting the heart, liver, or kidneys.
Choice D rationale
Polyuria, or excessive urination, is not a symptom of peritonitis. Peritonitis primarily affects the abdominal cavity and symptoms include severe abdominal pain, fever, and a rigid abdomen. Polyuria is often associated with conditions like diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Passing of flatus indicates that the gastrointestinal tract is functioning, which is an important sign after colostomy surgery.
Choice A rationale
A pinkish-red stoma indicates good blood supply, but does not confirm colostomy functionality alone.
Choice C rationale
Absent bowel sounds could indicate a potential postoperative ileus, which is a concern rather than a positive sign.
Choice D rationale
Tolerating a clear liquid diet indicates some gastrointestinal function but is not specific to colostomy functionality.
Correct Answer is A
Explanation
Choice A rationale
Aligning the client's joints with the joints on the CPM device frame ensures proper movement and prevents injury or discomfort. Correct alignment is crucial for effective therapy and to avoid strain on the joints.
Choice B rationale
High-Fowler's position is typically used for respiratory issues and does not align with the use of a CPM device for knee arthroplasty. Proper positioning is essential for the device's function.
Choice C rationale
Using a thick pillow to pad the CPM device could interfere with the device's movement and efficacy. Proper padding should ensure comfort without hindering the machine's operation.
Choice D rationale
Setting the degree of flexion and extension as tolerated by the client is important, but it should be done under medical guidance to ensure therapeutic benefits and avoid injury. Alignment is the primary concern.
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