A 68-year-old female client is being seen for follow-up wound care on her right lower leg. During her visit, the client states she hasn't had a bowel movement since her last visit a week ago. The client states she hasn't had much of an appetite in the past few days and says, "l figure I don't have anything in there to come out." The nurse auscultates the client's abdomen and hears hyperactive high-pitched bowel sounds in the upper left quadrant and hypoactive bowel sounds in the lower left quadrant. The nurse collaborates with the primary health care provider and the client is directly admitted to the hospital for possible intestinal obstruction. Before going to the hospital, the client asks the nurse what to expect. Which of these statements by the nurse (is) most likely accurate?
Select all that apply.
You should drink lots of water to help move the stool out of your body.
Surgery will be necessary to remove any Obstruction.
A nasogastric (NG) tube will be placed to relieve distention.
An abdominal CT will determine if you have an intestinal obstruction.
Correct Answer : C,D
Option A is not the best advice because drinking lots of water alone may not be enough to relieve constipation, especially if there is an obstruction.
Option B is also not accurate because not all intestinal obstructions require surgery, and the treatment approach will depend on the cause and severity of the obstruction.
Option C is accurate because a nasogastric tube can help relieve any distention caused by the obstruction by removing any gas or fluids that may have accumulated in the stomach and small intestine.
Option D is also accurate because an abdominal CT is one of the diagnostic tests that can help confirm the presence of intestinal obstruction and provide information about the location and cause of the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. The initial management of DKA involves fluid resuscitation with intravenous normal saline to correct dehydration and electrolyte imbalances. Therefore, starting an infusion of normal saline at 125 ml/hr is the first prescribed action the nurse should implement.
Bringing the patient a meal is not a priority at this time because the patient's blood glucose levels need to be stabilized before they can safely consume food. Administering Lantus insulin IV and giving sodium bicarbonate 50 mEq IV push are also not the first-line treatments for DKA. Lantus insulin is a long-acting insulin used to treat hyperglycemia over an extended period and should not be given intravenously. Sodium bicarbonate may be used to correct acidosis, but it is not the first priority in DKA management.
Correct Answer is D
Explanation
Yes, that's correct. Insulin lispro (Humalog) is a rapid-acting insulin, which means it begins to work quickly after injection, usually within 15 minutes, and it peaks in about 1 to 2 hours. It typically lasts for 3 to 4 hours in the body.
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