The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Continue to monitor the client as a paralytic ileus is possible

Administer the PRN stool softener to the client

Obtain an order to insert a nasogastric tube set to low suction

Report the assessment findings to the surgeon

Answer and Explanation

The Correct Answer is D

A. Continue to monitor the client as a paralytic ileus is possible

Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.

B. Administer the PRN stool softener to the client

A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.

C. Obtain an order to insert a nasogastric tube set to low suction

An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.

D. Report the assessment findings to the surgeon

Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.

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Correct Answer is C

Explanation

A. Sudden onset of chest pain and copious sputum

These are more consistent with pulmonary edema or a respiratory infection, not DIC.

B. Foul-smelling concentrated urine

This is suggestive of a urinary tract infection (UTI) or dehydration but is not a hallmark sign of DIC.

C. Oozing blood from IV sites & previous venipuncture sites

DIC is a disorder of excessive clotting and subsequent bleeding. Uncontrolled bleeding from IV sites, surgical wounds, or mucous membranes is a classic sign.

D. Reddened, inflamed central line catheter site

While redness around a catheter site may indicate infection, it is not a defining feature of DIC.

A. Administer each unit of blood over 34 hour B. Anticipate an order for acetaminophen C. Anticipate an order for furosemide administration D. Assess for signs and symptoms of fluid overload E. Anticipate administration of FFP for the next transfusion

Correct Answer is ["A","C","D"]

Explanation

A. Administer each unit of blood over 3–4 hours

Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.

B. Anticipate an order for acetaminophen

Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.

C. Anticipate an order for furosemide administration

Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.

D. Assess for signs and symptoms of fluid overload

CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.

E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion

FFP is given for coagulation disorders, not for treating anemia in a GI bleed.

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The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

Correct Answer is C

Explanation

The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

Correct Answer is ["A","C","D"]

Explanation

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