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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.

B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.

The priority is to determine the client's immediate physiological status.

C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of

nausea and refusal of breakfast.

D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.

A. Determine the patency of the tubing. B. Notify the provider. C. Offer oral fluids. D. Administer a prescribed analgesic.

Correct Answer is A

Explanation

a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.

b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.

c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.

d. Administer a prescribed analgesic: Pain management is important postoperatively, but the

immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.

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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 a client who has heart failure and has been taking digoxin 0.25 mg daily.The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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