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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Pantothenic acid (vitamin B5) is involved in fatty acid metabolism and coenzyme A synthesis, while vitamin B6 (pyridoxine) is crucial for amino acid metabolism and neurotransmitter synthesis. Prednisone does not typically lead to deficiencies in these vitamins.
Choice B rationale
Biotin (vitamin B7) plays a role in carbohydrate, fat, and protein metabolism, and vitamin B2 (riboflavin) is essential for cellular respiration and energy production. Prednisone therapy is not directly linked to a need for these supplements.
Choice C rationale
Folic acid (vitamin B9) is necessary for DNA synthesis and cell division, and vitamin C (ascorbic acid) is an antioxidant involved in collagen synthesis and immune function. Prednisone's effects do not primarily target these metabolic pathways to cause deficiencies.
Choice D rationale
Long-term prednisone therapy can lead to bone demineralization by increasing osteoclast activity and decreasing calcium absorption in the gut, thus increasing the risk of osteoporosis. Vitamin D is essential for calcium absorption and bone health. Supplementation with calcium and vitamin D helps to mitigate these adverse effects of prednisone. Normal serum calcium levels range from 8.5 to 10.5 mg/dL, and normal vitamin D levels are generally considered to be between 20 to 50 ng/mL, although optimal levels may vary.
Correct Answer is B
Explanation
Choice A rationale
Obtaining a dietary history is important in managing ulcerative colitis, as certain foods can exacerbate symptoms. However, in an acute exacerbation, the immediate priority is to address physiological instability, which electrolyte imbalances can significantly contribute to.
Choice B rationale
During an acute exacerbation of ulcerative colitis, patients can experience significant fluid and electrolyte losses due to frequent and bloody diarrhea. Reviewing electrolyte values, such as potassium, sodium, and magnesium, is the priority to identify and promptly correct any imbalances that could lead to cardiac arrhythmias or other complications. Normal ranges for serum electrolytes are: Sodium: 135-145 mEq/L, Potassium: 3.5-5.0 mEq/L, Chloride: 98-106 mEq/L, Bicarbonate: 22-26 mEq/L, Calcium: 8.5-10.5 mg/dL, Magnesium: 1.5-2.5 mEq/L.
Choice C rationale
Checking perianal skin integrity is important because frequent diarrhea can lead to skin breakdown. However, this assessment is secondary to addressing potential life-threatening electrolyte imbalances that can occur during an acute flare-up.
Choice D rationale
Addressing the patient's emotional concerns is a crucial aspect of holistic care for patients with chronic conditions like ulcerative colitis. However, in the context of an acute exacerbation, the immediate physiological needs, such as identifying and correcting electrolyte imbalances, take precedence.
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