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?
Incisional infection
Paralytic ileus
Health care-associated Clostridium difficile
Fecal impaction
The Correct Answer is B
b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.
c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.
d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the
rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Postictal phase: The postictal phase refers to the period following a seizure during which the individual may be drowsy, confused, or sleepy. This phase can last varying amounts of time.
b. Presence of absence seizures: Absence seizures are characterized by brief episodes of staring and altered consciousness but do not typically have a postictal phase with prolonged sleepiness.
c. Aura phase: The aura phase occurs before a seizure and involves sensory or perceptual changes that serve as a warning sign. It does not describe the postictal state.
d. Presence of automatisms: Automatisms are repetitive, non-purposeful movements that can occur during certain types of seizures but do not describe the postictal state of sleepiness.
Correct Answer is D
Explanation
a. Decrease the IV fluid infusion rate and limit oral fluid intake: The client's BUN and creatinine levels are not significantly elevated, and limiting fluid intake may exacerbate dehydration.
Decreasing the IV fluid rate may not be indicated without further assessment.
b. Collect a urine specimen for culture and sensitivity: While obtaining a urine specimen is
important, the priority in this case is to evaluate the urine output for amount and specific gravity to assess renal function and fluid balance.
c. Continue routine care because the results are within the expected reference range: The elevated BUN, along with nausea and vomiting, suggests the need for further assessment rather than
continuing routine care without adjustments.
d. Evaluate urine output for amount and urine for specific gravity: This is the correct action to assess renal function and fluid balance. Monitoring urine output and specific gravity will help determine if the client's kidneys are effectively concentrating urine and adequately excreting waste products.
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