The nursing student is writing a problem list for a client just admitted with a total small bowel obstruction. Which problem should the instructor ask?
Excess Fluid Volume: Intravascular.
Risk for Ineffective Tissue Perfusion: Gastrointestinal.
Risk for infection.
Acute pain assessment.
The Correct Answer is B
Choice A rationale
Excess fluid volume: intravascular is less relevant as it is more associated with conditions such as heart failure rather than bowel obstruction. Fluid shifts in bowel obstruction usually lead to third-spacing rather than intravascular volume excess.
Choice B rationale
Risk for ineffective tissue perfusion: gastrointestinal is correct as bowel obstruction can compromise blood flow to the intestines, leading to ischemia and necrosis. This is a critical concern that needs to be monitored and managed promptly.
Choice C rationale
Risk for infection is a valid concern but not the primary issue compared to tissue perfusion risks. Infection risk typically becomes more prominent if there are signs of bowel perforation or necrosis.
Choice D rationale
Acute pain assessment is important but is an aspect of managing the current problem rather than listing the primary problem itself. Pain management should follow once the main problem has been identified.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Entering a copy of the patient's physician's orders for life-sustaining treatment in the electronic medical record is not a violation of privacy. It is standard practice to document such orders to ensure all healthcare providers are aware of the patient's wishes.
Choice B rationale
Giving change of shift report to the oncoming RN and CNA at the patient's bedside, with the patient's consent, is not a privacy violation. It ensures continuity of care and involves the patient in their care plan.
Choice C rationale
Explaining the meaning of an advanced directive to the patient is part of patient education and is not a violation of privacy. It is essential for patients to understand their options for future healthcare decisions.
Choice D rationale
Looking up the lab results for a neighbor's former spouse without a legitimate reason is a breach of privacy. Nurses must only access patient information that is necessary for their job role and responsibilities.
Correct Answer is D
Explanation
Choice A rationale
Hypoactive bowel sounds are common post-operatively due to anesthesia and immobility, so they are not the most concerning immediate finding.
Choice B rationale
Intermittent incisional pain rated 7/10 is significant but expected post-operatively, and manageable with pain control measures.
Choice C rationale
Blood pressure of 110/70 and heart rate of 86 are within normal ranges, so these are not alarming post-operative signs.
Choice D rationale
Increased restlessness can indicate pain, anxiety, or potentially worsening condition, making it the most concerning and requiring immediate attention.
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