What is a likely finding in the nurse's assessment of a patient who has a large bowel obstruction?
Referred back pain.
Abdominal distention.
Projectile vomiting.
Metabolic alkalosis.
The Correct Answer is B
Choice A rationale
Referred back pain is not a hallmark of large bowel obstruction. It typically occurs in conditions with retroperitoneal organ involvement, such as renal or pancreatic pathology. Large bowel obstruction presents primarily with abdominal distention and pain localized to the affected bowel segment due to obstruction-induced pressure and stretching.
Choice B rationale
Abdominal distention is a classic sign of large bowel obstruction. Accumulated gas and stool proximal to the obstruction result in bloating and visible distention. This presentation reflects impaired bowel motility, pressure build-up, and reduced passage of contents, commonly seen in large bowel pathology.
Choice C rationale
Projectile vomiting is more indicative of upper GI obstruction, such as pyloric stenosis, due to immediate pressure effects. Large bowel obstructions manifest with late vomiting as distal obstruction delays content passage. Vomiting in this case is less forceful and often accompanied by fecal material.
Choice D rationale
Metabolic alkalosis is more associated with vomiting-related losses of gastric acid, as seen in upper GI pathology. Large bowel obstruction typically leads to metabolic acidosis from ischemia or bacterial overgrowth, not alkalosis, as the obstruction hampers normal bowel function and circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Checking plantar and dorsiflexion assesses neurological status requiring nursing expertise and cannot be delegated to UAP.
Choice B rationale
Log rolling every 2 hours maintains spinal alignment post-laminectomy, a straightforward, standardized task suitable for experienced UAP.
Choice C rationale
PCA assessment involves evaluating pain control methods, which require critical nursing judgments and is not appropriate to delegate.
Choice D rationale
Determining readiness to ambulate involves comprehensive assessment skills, evaluating multiple factors like pain, strength, and hemodynamic stability, beyond UAP’s scope of practice. .
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.
Choice B rationale
Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.
Choice C rationale
Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.
Choice D rationale
A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.
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