Which finding would most concern the nurse when caring for a client diagnosed with a bowel obstruction?
Urine specific gravity 1.035.
Pain colicky in nature.
Serum sodium 132 mEq/L.
Frank blood in the N/G suction container.
The Correct Answer is D
Choice A rationale
Urine specific gravity of 1.035 indicates dehydration, which is concerning but not the most critical issue in a client with a bowel obstruction.
Choice B rationale
Colicky pain is typical of bowel obstruction as the intestines try to move contents past the obstruction, and while concerning, it is expected.
Choice C rationale
Serum sodium of 132 mEq/L indicates mild hyponatremia, which is concerning but not immediately life-threatening in the context of bowel obstruction.
Choice D rationale
Frank blood in the N/G suction container indicates possible bowel ischemia or perforation, which requires immediate intervention and is the most concerning finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
After an open cholecystectomy, bowel sounds are typically absent or hypoactive due to the effects of anesthesia and the manipulation of the intestines during surgery. It takes time for normal bowel function to resume.
Choice A rationale
Normoactive bowel sounds are not expected immediately after abdominal surgery due to the temporary paralysis of intestinal motility caused by anesthesia and surgical manipulation.
Choice C rationale
Hyperactive bowel sounds are uncommon after surgery. They are more often associated with conditions like gastroenteritis or bowel obstruction rather than the immediate postoperative period of an open cholecystectomy.
Choice D rationale
Borborygmi, or loud, rumbling bowel sounds, are not expected after abdominal surgery. These sounds can indicate increased bowel activity, which is not typical in the immediate postoperative phase following an open cholecystectomy.
Correct Answer is D
Explanation
Choice A rationale
Urine specific gravity of 1.035 indicates dehydration, which is concerning but not the most critical issue in a client with a bowel obstruction.
Choice B rationale
Colicky pain is typical of bowel obstruction as the intestines try to move contents past the obstruction, and while concerning, it is expected.
Choice C rationale
Serum sodium of 132 mEq/L indicates mild hyponatremia, which is concerning but not immediately life-threatening in the context of bowel obstruction.
Choice D rationale
Frank blood in the N/G suction container indicates possible bowel ischemia or perforation, which requires immediate intervention and is the most concerning finding.
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