The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?
Fecal impaction
Incisional infection
Health care-associated Clostridium difficile
Paralytic ileus
The Correct Answer is D
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While relaxation techniques are beneficial, providing structure is often the first step in helping clients with OCD manage their symptoms, as it can reduce anxiety and prevent time for obsessions and compulsions to occur.
Choice B reason: A structured schedule can help the client focus on tasks and activities, reducing the time available for obsessive thoughts and compulsive behaviors.
Choice C reason: Identifying expectations is important, but it should come after establishing a structured routine that can support the client's participation in care.
Choice D reason: Discussing alternative coping strategies is a part of treatment, but initially providing a structured schedule can offer immediate relief and a sense of control for the client.
Correct Answer is D
Explanation
Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.
Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.
Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.
Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.
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