The nurse caring for a client admitted with peritonitis who has developed a paralytic ileus. While auscultating bowel sounds, the nurse assesses flatus. What is the significance of this finding? 43
Select one:
Gas has formed in bowel contents.
Flatus indicates inadequate decompression.
Flatus results from forceful vomiting.
Flatus indicates returning peristalsis.
The Correct Answer is D
A. Gas forming in bowel contents may occur due to bacterial activity, but this does not explain the clinical significance of flatus in the context of paralytic ileus recovery.
B. Flatus indicating inadequate decompression is incorrect; flatus usually suggests that gas is moving through the intestines, not that it is accumulating.
C. Flatus resulting from forceful vomiting is inaccurate; vomiting expels stomach contents, not intestinal gas, and does not produce flatus.
D. The passage of flatus is a key sign that bowel motility is resuming, which is especially significant in a client with a previously diagnosed paralytic ileus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Edema is more commonly due to fluid overload and impaired renal excretion of sodium and water, not primarily caused by low potassium levels.
B. Seizures are more typically linked to electrolyte imbalances such as low sodium or low calcium, not potassium.
C. Respiratory depression is more commonly associated with opioid use, high magnesium, or neuromuscular suppression, not hypokalemia.
D. Critically low potassium (hypokalemia) impairs normal cardiac conduction and increases the risk for life-threatening arrhythmias, making this the most dangerous and priority complication to monitor for.
Correct Answer is B
Explanation
A. While tracking intake and output is important, it does not directly address the patient’s current complaint or help identify urinary retention.
B.The first action is to assess the bladder for distention by palpating above the symphysis pubis. This helps determine if the bladder is full and not emptying, which may indicate urinary retention.
C. Encouraging natural voiding techniques (like running water) is appropriate, but only after assessment confirms the bladder is not overly distended.
D. Notifying the provider is important if interventions fail, but the nurse should first assess before escalating the situation.
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