A burse is assessing a client who is 3 days postoperative and has a nonmechanical obstruction of the small bowel. Which of the following findings should the nurse expect?
Metabolic acidosis
Hyperactive bowel sounds
Distended abdomen
Passing flatus
The Correct Answer is C
A. Metabolic acidosis: Small bowel obstructions are more commonly associated with metabolic alkalosis due to loss of gastric contents from vomiting. Acidosis is less typical in the early stages of obstruction.
B. Hyperactive bowel sounds: In nonmechanical (paralytic ileus) obstruction, bowel sounds are usually absent or hypoactive, not hyperactive, due to lack of peristalsis. Hyperactive sounds are more typical in early mechanical obstruction.
C. Distended abdomen: Abdominal distention is a classic sign of bowel obstruction, resulting from gas and fluid accumulation above the site of obstruction. It is expected in both mechanical and nonmechanical types.
D. Passing flatus: The absence of flatus is common in bowel obstruction, as bowel movement is halted. Continued passage of flatus would suggest partial or resolving obstruction, not a typical finding in active nonmechanical obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer propranolol IV to the client: Propranolol is a beta-blocker used to treat hypertension and certain cardiac conditions. It is not indicated for sudden nausea during pregnancy and could be harmful if administered without cause.
B. Position the client on her side: At 36 weeks, the gravid uterus can compress the inferior vena cava when the client lies flat, reducing venous return and causing supine hypotensive syndrome, which often presents as nausea. Turning the client to her side relieves pressure and restores circulation.
C. Ask the client to increase her daily calcium intake: Calcium is important during pregnancy, especially for bone health, but increasing intake is not an acute intervention for nausea caused by positional blood flow issues.
D. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers assess fetal position but do not address the client’s immediate symptom of nausea, which may indicate compromised circulation from lying supine. Position change is the priority action.
Correct Answer is ["A","D","E"]
Explanation
A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to the feeding and prevents aspiration or overfeeding.
B. Ensure the formula is cold before administration: Cold formula can cause gastric cramping and discomfort. It should be at room temperature prior to administration.
C. Check placement of the feeding tube x-ray once daily: X-ray confirmation is typically done once upon initial insertion. Daily checks are not required unless there’s a concern about displacement.
D. Change the feeding container and tubing every 24 hr: This reduces the risk of bacterial contamination, especially since enteral nutrition provides a medium for microbial growth.
E. Maintain the head of the client’s bed at a 30° angle or higher: Elevating the head of the bed helps prevent aspiration by keeping gastric contents from refluxing into the esophagus.
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