A nurse is reviewing the provider's prescriptions for a client experiencing a paralytic ileus following an appendectomy.
Which of the following actions should the nurse expect to take?

Insert nasogastric tube.

Provide a bulk-forming agent.

Administer an antacid.

Apply a truss.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Insertion of a nasogastric tube is expected in a client with paralytic ileus to decompress the bowel by removing accumulated fluids and gas. Paralytic ileus is a non-mechanical obstruction of the bowel characterized by a lack of peristalsis, often occurring after abdominal surgery like an appendectomy. This decompression helps relieve abdominal distension, pain, and nausea, facilitating the return of bowel function.

Choice B rationale

Providing a bulk-forming agent, such as psyllium, is contraindicated in paralytic ileus. Bulk-forming agents work by increasing the volume of stool, which would exacerbate the obstruction and potentially cause further discomfort and complications in the absence of peristalsis. These agents are typically used to treat constipation by adding fiber to the diet and promoting bowel movements.

Choice C rationale

Administering an antacid, such as aluminum hydroxide or calcium carbonate, is not a primary intervention for paralytic ileus. Antacids work by neutralizing stomach acid and are used to treat conditions like heartburn and acid reflux. While a client with paralytic ileus might experience some gastric upset, the underlying issue is the lack of bowel motility, which antacids do not address.

Choice D rationale

Applying a truss is used to provide support for hernias, a condition unrelated to paralytic ileus following an appendectomy. A truss helps to keep the protruding tissue in place and reduce discomfort associated with the hernia. It does not address the underlying lack of bowel motility characteristic of paralytic ileus.

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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.

A. Weight loss B. Knuckle deformity C. Low-grade fever D. Anorexia

Correct Answer is B

Explanation

Choice A rationale

Weight loss can occur at various stages of rheumatoid arthritis due to chronic inflammation and increased metabolic demands. While it can be present later in the disease, it is not specifically identified as a late manifestation. Systemic inflammation leads to the release of pro-inflammatory cytokines, which can affect appetite and metabolism, contributing to weight changes throughout the course of the disease.

Choice B rationale

Knuckle deformities, such as swan neck and boutonniere deformities, are characteristic late manifestations of rheumatoid arthritis. These deformities result from chronic inflammation and synovial proliferation leading to damage of the tendons, ligaments, and joint capsule around the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Over time, this causes the characteristic changes in finger alignment.

Choice C rationale

Low-grade fever can be a systemic manifestation of the inflammatory process in rheumatoid arthritis, but it is more commonly seen during active flares and is not specifically classified as a late manifestation. The fever is a result of the release of pyrogens, such as interleukin-1 and tumor necrosis factor-alpha, during periods of heightened immune activity. Normal body temperature ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C).

Choice D rationale

Anorexia, or loss of appetite, can be associated with the chronic pain and systemic inflammation of rheumatoid arthritis at any stage. Inflammatory cytokines can affect appetite regulation in the hypothalamus. While it might persist in later stages, it is not a definitive late manifestation compared to structural joint changes.

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A nurse is reviewing the provider's prescriptions for a client experiencing a paralytic ileus following an appendectomy.Which of the following actions should the nurse expect to take?

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A nurse is reviewing the provider's prescriptions for a client experiencing a paralytic ileus following an appendectomy.
Which of the following actions should the nurse expect to take?