A nurse is planning care for a client who is postoperative and at risk for paralytic ileus.
Which of the following interventions should the nurse plan to take to promote peristalsis?
Decrease fluid intake.
Offer the client the bedpan every 2 hr.
Increase protein intake.
Increase ambulation.
The Correct Answer is D
Choice A rationale
Decreasing fluid intake can lead to dehydration and constipation, which would further impede peristalsis rather than promote it. Adequate hydration is essential for maintaining bowel regularity and facilitating the movement of intestinal contents.
Choice B rationale
Offering the bedpan every 2 hours does not directly stimulate peristalsis. While it provides an opportunity for bowel elimination, it does not address the underlying issue of decreased intestinal motility associated with paralytic ileus.
Choice C rationale
Increasing protein intake does not directly promote peristalsis. While protein is important for overall healing, it does not have a significant impact on stimulating bowel motility. Fiber intake is more directly related to promoting bowel function.
Choice D rationale
Increased ambulation stimulates peristalsis by promoting intestinal motility. Physical activity helps to move gas and fluids through the intestines, reducing the risk of paralytic ileus, which is a functional obstruction of the bowel often occurring after surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Migraine headaches are a common comorbidity associated with fibromyalgia. Studies suggest a shared pathophysiology involving central sensitization and altered pain processing mechanisms in the central nervous system that contribute to both conditions.
Choice B rationale
Weather changes, particularly fluctuations in barometric pressure, temperature, and humidity, are frequently reported by individuals with fibromyalgia as triggers for increased pain and other symptoms like stiffness and fatigue. The exact mechanisms are not fully understood but may involve changes in tissue pressure and nerve sensitivity.
Choice C rationale
Chest pain, specifically non-cardiac chest pain, is a recognized symptom in some individuals with fibromyalgia. This pain is often musculoskeletal in origin, arising from tender points in the chest wall and surrounding muscles, and is not related to cardiac issues.
Choice D rationale
Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues. Unlike rheumatoid arthritis or osteoarthritis, fibromyalgia does not involve joint inflammation or structural damage to the joints. The pain is believed to originate from amplified pain signals in the brain and spinal cord.
Correct Answer is A
Explanation
Choice A rationale
A 24-hour urinary output of 380 mL falls below the generally accepted threshold for oliguria in adults. This reduced output could indicate kidney dysfunction or decreased renal perfusion following surgery.
Choice B rationale
A 24-hour urinary output of 600 mL is within the low end of the normal range for adult urinary output, which is generally considered to be 800 mL to 2000 mL per 24 hours.
Choice C rationale
A 24-hour urinary output of 550 mL is also within the low end of the normal range for adult urinary output. While lower than average, it does not meet the criteria for oliguria.
Choice D rationale
A 24-hour urinary output of 720 mL is within the normal range for adult urinary output and does not indicate oliguria.
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