The nurse plans care for a client recovering from a Whipple procedure. The nurse notes a distended abdomen with absent bowel sounds, and the client denies passing flatus. Which action should the nurse include in the plan of care?
Encourage the client to take deep breaths.
Encourage the client to increase oral fluids.
Maintain a patent nasogastric tube.
Administer a laxative of choice.
The Correct Answer is C
Rationale:
A. Deep breathing exercises are important for preventing postoperative pulmonary complications, but they do not address bowel obstruction or ileus, which are indicated by abdominal distention, absent bowel sounds, and no flatus.
B. Oral intake is contraindicated in the presence of absent bowel sounds and abdominal distention after a Whipple procedure, as it can worsen nausea, vomiting, and risk of aspiration. Oral fluids should only be advanced once bowel function returns.
C. The client’s signs—abdominal distention, absent bowel sounds, and no flatus—indicate postoperative paralytic ileus or small bowel obstruction, common after a Whipple procedure. A nasogastric (NG) tube decompresses the stomach and intestines, relieves nausea and vomiting, prevents aspiration, and reduces abdominal distention until normal bowel function resumes. Ensuring the NG tube remains patent is a priority nursing intervention.
D. Laxatives are contraindicated when bowel sounds are absent, as stimulating bowel activity before the resolution of ileus or obstruction can cause bowel perforation or severe abdominal pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. This statement demonstrates that the client has a realistic expectation of recovery after an acute exacerbation of chronic pancreatitis. Typically, after an exacerbation, clients may need several weeks to regain strength and resume normal activities. The nurse does not need to change the teaching plan based on this statement, as it aligns with recovery guidelines.
B. Engagement in social and community activities supports emotional well-being and recovery. Continuing normal activities within the limits of physical tolerance is encouraged, and this statement indicates the client is planning to maintain a healthy social life. No modification of the teaching plan is necessary.
C. This statement raises a major concern because alcohol consumption is a primary risk factor for exacerbations of chronic pancreatitis. Even small amounts of alcohol can trigger inflammation, cause pain, or worsen pancreatic function. The nurse must intervene by revising the teaching plan to emphasize strict alcohol avoidance, discuss alternative ways to socialize without alcohol, and reinforce the importance of lifestyle modifications to prevent recurrent attacks. This statement indicates a knowledge gap or misunderstanding, making it the reason for changing the teaching plan.
D. Positive support systems, such as a caring spouse, enhance adherence to treatment recommendations and overall recovery. This statement reflects the client’s recognition of social support, which is beneficial for both physical and emotional recovery. No teaching changes are needed based on this comment.
Correct Answer is ["13"]
Explanation
Step 1: Convert weight from pounds to kilograms
Weight (kg) = 193 ÷ 2.2
Weight ≈ 87.7 kg
Step 2: Calculate the ordered dose in mcg/min
Dose (mcg/min) = 2.5 mcg/kg/min × 87.7 kg
Dose ≈ 219.25 mcg/min
Step 3: Convert mcg/min to mg/hr
219.25 mcg/min × 60 min/hr = 13,155 mcg/hr
13,155 mcg/hr ÷ 1,000 mcg/mg = 13.155 mg/hr
Step 4: Determine concentration of IV solution
250 mg in 250 mL
Concentration = 1 mg/mL
Step 5: Calculate mL/hr
mL/hr = 13.155 mg/hr ÷ 1 mg/mL
mL/hr ≈ 13.155 mL/hr
Step 6: Round to the nearest whole number
13.155 = 13 mL/hr
Final Answer: 13 mL/hr
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