On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

Administering a PRN cathartic.

Reducing IV fluid to a keep-open rate.

Advancing diet to full liquids.

Insertion of a nasogastric tube.

Answer and Explanation

The Correct Answer is D

Choice A reason: A cathartic is contraindicated, as pain, distension, and absent bowel sounds suggest postoperative ileus or obstruction, where peristalsis is impaired. Cathartics risk perforation. A nasogastric tube decompresses the bowel, addressing gastrointestinal stasis, preventing complications like vomiting or rupture.

Choice B reason: Reducing IV fluids does not address pain, distension, or absent bowel sounds, indicating ileus or obstruction. Fluids maintain hydration, but nasogastric tube insertion relieves bowel pressure from gas and fluid, restoring function, making fluid reduction ineffective for this postoperative complication.

Choice C reason: Advancing to liquids is inappropriate with absent bowel sounds and distension, indicating ileus, risking vomiting or aspiration. A nasogastric tube removes gastric contents, allowing bowel recovery. Oral intake worsens obstruction, making this contraindicated compared to decompression for safe recovery.

Choice D reason: Nasogastric tube insertion is critical for pain, distension, and absent bowel sounds, suggesting postoperative ileus or obstruction. It decompresses the stomach, removing gas and fluid, reducing pressure and preventing perforation. This addresses the pathophysiological basis of impaired motility, ensuring safe postoperative recovery.

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Correct Answer is B

Explanation

Choice A reason: Assessing blood return checks patency, but pain suggests infiltration or phlebitis, where saline leaks into tissues. Stopping the infusion prevents further tissue damage, as extravasation causes swelling or necrosis, especially in dehydrated elderly clients, making assessment secondary to halting infusion.

Choice B reason: Stopping the saline infusion is the priority, as pain at the IV site suggests infiltration or phlebitis, with fluid irritating tissues or veins. Halting infusion prevents damage, allowing safe assessment and management, critical in fragile elderly veins, ensuring no further harm during rehydration.

Choice C reason: Establishing new IV access is necessary post-infiltration but not first. Pain indicates ongoing tissue irritation from saline leakage, requiring immediate infusion cessation to prevent damage. Stopping the infusion ensures safety before reattempting access, critical in dehydrated patients needing fluid replacement.

Choice D reason: Selecting a different gauge needle is irrelevant, as the 24-gauge catheter is placed, and pain indicates infiltration, not size. Stopping the infusion prevents extravasation, which risks compartment syndrome in elderly clients, making this less immediate than halting the infusion for safety.

A. Administer an IV narcotic analgesic. B. Adjust compression device until client is comfortable. C. Turn the client to a left side-lying position. D. Assess the femoral PCI access site for a hematoma.

Correct Answer is D

Explanation

Choice A reason: Administering an IV narcotic masks pain without addressing its cause. Pain at the PCI site may indicate hematoma or arterial injury, common post-PCI due to vessel trauma and tirofiban’s antiplatelet effects. Assessing the site identifies bleeding, critical to prevent complications like hemorrhage before providing analgesia.

Choice B reason: Adjusting the compression device without assessment risks worsening a hematoma, as excessive pressure impairs flow, while insufficient pressure fails to control bleeding. Tirofiban increases bleeding risk. Assessing for hematoma ensures proper management, preventing vascular complications, making adjustment premature without confirming the pain’s cause.

Choice C reason: Turning to a left side-lying position does not address PCI site pain, potentially from hematoma or arterial injury. Post-PCI, supine positioning minimizes site stress. Assessing for hematoma, exacerbated by tirofiban’s anticoagulation, is critical to detect bleeding, preventing complications like retroperitoneal hemorrhage over positional changes.

Choice D reason: Assessing the femoral PCI site for hematoma is essential, as pain may indicate bleeding, common post-PCI with tirofiban’s platelet inhibition. Hematoma can compress vessels, causing ischemia or rupture, requiring urgent intervention like compression or surgery. This addresses the pathophysiological risk, ensuring vascular stability and patient safety.

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On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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