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 B
Explanation
Choice A rationale
Sulfasalazine is more commonly associated with side effects such as gastrointestinal discomfort and hypersensitivity reactions, rather than causing bruising. Monitoring for bruising is not a specific intervention for this medication.
Choice B rationale
Ensuring the client drinks at least 2000 mL of water daily helps prevent crystal formation in the kidneys, a potential side effect of sulfasalazine. Adequate hydration also supports overall renal function and reduces the risk of kidney stones.
Choice C rationale
Sulfasalazine is usually taken multiple times a day with meals to reduce gastrointestinal side effects and improve absorption. Administering it once a day before breakfast is not the typical dosing schedule.
Choice D rationale
While it is important to monitor the client's stool, steatorrhea (fatty stools) and mucus are not specifically associated with sulfasalazine. The primary focus is on ensuring hydration and monitoring for other side effects such as rash and gastrointestinal discomfort.
Correct Answer is D
Explanation
Choice A rationale
Increasing fluid intake does not directly influence the prevention of biliary colic related to cholecystitis. While staying hydrated is important, it is not the primary preventive measure for colic.
Choice B rationale
Stopping the use of narcotics can help reduce pain and other symptoms, but it is not essential for the prevention of biliary colic. Pain management should be tailored to the individual's needs.
Choice C rationale
Remaining in the supine position is not a recommended practice to prevent the development of biliary colic. Mobility and certain positioning (such as sitting or semi-Fowler’s) may be more beneficial.
Choice D rationale
Decreasing the intake of fat in the diet is essential in the prevention of biliary colic related to cholecystitis. Fatty foods can trigger gallbladder contractions, which may cause pain and exacerbate symptoms.
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