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 A
Explanation
Choice A rationale
Formation of fistulas (abnormal connections between organs) and abscesses (collections of pus) are characteristic complications of Crohn's disease. The transmural inflammation in Crohn's disease can penetrate through the bowel wall, leading to these developments.
Choice B rationale
Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus, although it most commonly involves the ileum and colon. Symptoms are not confined to the large intestine. Ulcerative colitis, another inflammatory bowel disease, primarily affects the colon.
Choice C rationale
While antibiotics may be used to treat secondary infections or complications of Crohn's disease, they are not a primary treatment for the underlying inflammatory process and do not typically lead to improvement of the disease itself. Crohn's disease is a chronic inflammatory condition that requires immunomodulatory or anti-inflammatory medications.
Choice D rationale
Rectal bleeding is more commonly associated with ulcerative colitis, where the inflammation is typically limited to the mucosal layer of the colon and rectum, leading to ulceration and bleeding. While some bleeding can occur in Crohn's disease, it is generally less prominent than in ulcerative colitis.
Correct Answer is D
Explanation
Choice A rationale
Patient-controlled analgesia is designed to allow patients to manage their pain proactively. Waiting until the pain is severe before using the device can lead to inadequate pain control and increased discomfort. The goal of PCA is to maintain a consistent level of analgesia by allowing the patient to self-administer small doses as needed.
Choice B rationale
PCA devices are programmed with safety limits, including lockout intervals and maximum doses, to prevent accidental overdosing. While the patient should understand how to use the button, the primary responsibility for preventing overdose lies with the device's safety mechanisms and the healthcare team's programming.
Choice C rationale
Allowing family members to push the PCA button bypasses the safety mechanisms built into the device, which are based on the patient's demand for pain relief. This practice can lead to over-sedation and respiratory depression if the patient is not the one experiencing the pain and needing the medication. The patient must be the only one to activate the PCA device.
Choice D rationale
If the PCA device is not effectively controlling the patient's pain, it indicates a need for reassessment of the medication, dosage, or delivery method. The nurse can then collaborate with the provider to make necessary adjustments to ensure adequate pain management. This statement demonstrates the client's understanding of the importance of communicating their pain level.
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