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 A

Explanation

A. Hepatotoxicity is not a primary sign of salicylate toxicity; salicylate toxicity is more commonly associated with gastrointestinal issues, mental confusion, and tinnitus.

B. GI bleeding is a common sign of salicylate toxicity due to its effect on the gastrointestinal lining.

C. Mental confusion can occur as a result of salicylate toxicity affecting the central nervous system.

D. Tinnitus is a classic symptom of salicylate toxicity.

A. The nurse disagrees with the nurse manager about inadequate staffing. B. The nurse discovers that client does not have advanced directives. C. A staff member has not arrived at the facility to work an assigned shift. D. A client tells the nurse that his dentures are missing.

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.

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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

Signs of Salicylate toxicity include all of the following except:

Correct Answer is A

Explanation

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 caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?

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A nurse is caring for a client who is 2 days postoperative from abdominal surgery. The client reports discomfort from abdominal distension and flatus. Which of the following suggestions should the nurse include?

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