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 C
Explanation
Choice A rationale
A T-tube does not reroute bile into the intestine. Its purpose is to drain bile externally from the common bile duct to prevent obstruction and ensure healing.
Choice B rationale
The T-tube is not used for visualization of the gallbladder or duct system during surgery. Instead, it provides an external bile drainage route postoperatively to avoid bile buildup.
Choice C rationale
The T-tube helps to maintain patency of the common bile duct by providing a direct drainage path for bile. This prevents bile from accumulating and causing complications like jaundice or infection.
Choice D rationale
Preventing leakage of bile onto the skin is not the primary purpose of a T-tube. Its main function is to ensure bile can bypass any postoperative swelling or blockage in the bile ducts.
Correct Answer is A
Explanation
Choice A rationale
Bariatric surgery requires significant lifestyle changes, and support groups can provide essential emotional and practical support. These groups offer shared experiences and strategies to help adhere to dietary and activity recommendations, which can be crucial for long-term success.
Choice B rationale
While suggesting a group can be helpful, this response focuses on the nurse's preferences rather than the client's autonomy and willingness to engage in support, which is less effective in fostering adherence.
Choice C rationale
Research indicates that support groups contribute to better post-surgery outcomes by providing mutual support and sharing coping strategies. However, the added question shifts the focus from the immediate benefit of the support group to an exploration of other resources, which can be less direct.
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