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?

Paralytic ileus

Incisional infection

Health care-associated Clostridium difficile

Fecal impaction

Answer and Explanation

The Correct Answer is A

A. Paralytic ileus is a common postoperative complication characterized by the absence of bowel sounds, abdominal distention, and failure to pass flatus due to a lack of intestinal peristalsis.

B. Incisional infection would typically present with localized symptoms such as redness, warmth, and purulent drainage at the surgical site, not generalized abdominal distention and lack of bowel sounds.

C. Health care-associated Clostridium difficile infection usually presents with diarrhea, not an absence of bowel sounds or abdominal distention.

D. Fecal impaction is more likely to cause localized pain and possible leakage of liquid stool, rather than complete absence of bowel sounds and severe distention.

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Correct Answer is D

Explanation

A. Disagreements about staffing issues should be addressed through appropriate channels, but they do not typically require an incident report.

B. The absence of advanced directives is a concern that needs to be addressed, but it does not constitute an incident that requires reporting.

C. A staff member not arriving for their shift is a staffing issue but does not require an incident report unless it directly affects client care.

D. Missing dentures are considered a loss of personal property, which requires documentation through an incident report to ensure accountability and to initiate a search or compensation process.

A. "It's unfortunate that I have to be in the hospital for this treatment." B. “I wish I didn't have to attach the electrodes to my skin." C. "I hope I don't have to take as many pain pills. D. “I’ll need to shave the hair off the skin where I place the electrodes."

Correct Answer is A

Explanation

A. The client does not need to be in the hospital for TENS therapy, as it is a non-invasive treatment that can be used at home. This statement indicates a misunderstanding that needs clarification.

B. While attaching electrodes to the skin is necessary for TENS therapy, expressing a dislike for this does not indicate a misunderstanding of the procedure.

C. Hoping to reduce pain medication is a reasonable expectation and indicates the client understands the purpose of TENS.

D. Shaving the area where the electrodes are placed is often recommended to ensure good contact and effectiveness of the treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for several clients on a medical-surgical unit. Which of the following client care situations requires the nurse to complete an incident report?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements by the client indicates the need for further teaching?

Correct Answer is A

Explanation

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