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. Clients with chronic renal failure often need dietary restrictions (e.g., low protein, low sodium, low potassium, fluid control) to reduce kidney workload and manage symptoms.
B. Monitoring and correcting imbalances in electrolytes like potassium, sodium, calcium, and fluid volume is a critical part of nursing care in chronic kidney disease.
C. When kidney function deteriorates significantly, dialysis becomes necessary to remove waste products and excess fluids from the blood.
D. Chronic renal failure patients are often unable to excrete sodium and potassium properly, so infusing them continuously would likely worsen electrolyte imbalances and lead to dangerous complications such as hyperkalemia or fluid overload. This is not a standard treatment.
Correct Answer is B
Explanation
A. Ketoacidosis typically presents with symptoms like nausea, vomiting, abdominal pain, fruity breath, and Kussmaul respirations—not acute shakiness or sweating.
B. The signs of sweating, tachycardia, light-headedness, and shakiness are classic early symptoms of hypoglycemia, a common complication in type 1 diabetes, especially when insulin or food intake is imbalanced.
C. Nephropathy is a chronic complication of diabetes affecting the kidneys and does not present with acute symptoms like those described.
D. Hyperglycemia usually causes polyuria, polydipsia, and fatigue but not the adrenergic (fight-or-flight) symptoms described here.
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