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 A
Explanation
A. Weighing clients is within the scope of an assistive personnel’s role, provided they have been properly trained in using facility equipment and understand the procedure. The nurse retains responsibility for ensuring the accuracy of the data and interpreting it.
B. This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.
C. Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.
D. Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.
Correct Answer is A
Explanation
A. Stop the procedure: Stopping the blood transfusion immediately is the priority to prevent further exposure to the potentially harmful blood product causing the wheezing. This action helps minimize the risk of progression to a more severe transfusion reaction or anaphylaxis.
B. Administer an antihistamine: Antihistamines may relieve allergic symptoms but should only be given after the transfusion is stopped and the client is assessed. Administering medication without stopping the transfusion first could worsen the reaction.
C. Administer oxygen: Providing oxygen supports the client’s respiratory function during wheezing, which may indicate hypoxia. Oxygen administration is important but secondary to stopping the transfusion to eliminate the cause.
D. Initiate an infusion of 0.9% sodium chloride using new tubing: Starting a saline infusion with new tubing helps maintain IV access and prevent clotting after stopping the transfusion. This action is necessary but follows stopping the transfusion as the first priority.
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