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
Basal cell carcinoma, the most common type of skin cancer, often presents as a raised, flesh-colored or pearly white papule or nodule with rolled, pearly borders and telangiectasia (visible small blood vessels). The description of the 1-cm raised, flesh-colored lesion with pearly white borders aligns with the typical appearance of basal cell carcinoma.
Choice B rationale
Malignant melanoma is characterized by its irregular shape, asymmetrical borders, uneven color (often with shades of black, brown, red, white, or blue), and diameter greater than 6 mm. It can arise from existing moles or appear as a new pigmented lesion. The described lesion does not fit this profile.
Choice C rationale
Actinic keratosis is a precancerous skin condition that appears as rough, scaly patches on sun-exposed areas. These lesions are typically flat or slightly raised and can be skin-colored, reddish-brown, or have a whitish scale. The description of a raised lesion with pearly borders is inconsistent with actinic keratosis.
Choice D rationale
Squamous cell carcinoma often presents as a firm, red nodule or a flat lesion with a scaly, crusted surface. It can also appear as a non-healing ulcer. While it can occur on the chest, the pearly white borders are more characteristic of basal cell carcinoma.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A client who is ambulatory following a cardiac catheterization 4 hours ago has increased mobility, which reduces the risk of prolonged pressure on bony prominences. The short duration post-procedure and ability to ambulate make this client less susceptible to pressure ulcer development.
Choice B rationale
Postoperative delirium can lead to decreased mobility, increased agitation and friction against surfaces, and impaired ability to communicate discomfort or reposition themselves. These factors significantly increase the risk of prolonged pressure and subsequent pressure ulcer formation.
Choice C rationale
Protein-calorie malnutrition results in decreased subcutaneous tissue and muscle mass, which normally provide cushioning over bony prominences. Poor nutritional status also impairs tissue repair and increases skin fragility, making the client highly susceptible to pressure ulcer development.
Choice D rationale
Right-sided heart failure can cause fluid overload and peripheral edema, particularly in the lower extremities. This edema increases tissue fragility and reduces blood flow to the skin, making it more susceptible to breakdown and pressure ulcer formation, especially in areas with bony prominences like heels and ankles.
Choice E rationale
While hyperglycemia in type 1 diabetes mellitus can impair wound healing and increase the risk of infection if a pressure ulcer develops, it is not a direct primary risk factor for the initial development of pressure ulcers. Immobility, malnutrition, and edema are more direct contributors to skin breakdown due to pressure.
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