A client had surgery yesterday and is reporting abdominal discomfort and lack of appetite. The nurse auscultates the abdomen and does not detect bowel sounds. The nurse suspected which type of bowel obstruction?
Volvulus
Paralytic ileus.
Surgical adhesions/scar tissue
Intestinal hernia.
The Correct Answer is B
A paralytic ileus is a type of bowel obstruction characterized by the impairment or absence of normal bowel motility. It occurs due to the temporary paralysis or dysfunction of the muscles that propel food and waste material through the intestines. After surgery, paralytic ileus can occur as a result of the handling of the intestines during the procedure, the effects of anesthesia, or the body's response to inflammation and trauma.
The absence of bowel sounds is a key indicator of paralytic ileus. Normally, bowel sounds are present and indicate the movement of contents through the intestines. However, in a paralytic ileus, the bowel sounds may be diminished or absent due to the lack of peristalsis (wave-like contractions that move food along the digestive tract).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.
While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.
Correct Answer is C
Explanation
The patient bending over the sink while brushing teeth requires intervention by the nurse. After hip arthroplasty using the posterior approach, the patient should avoid bending at the hip greater than 90 degrees to prevent dislocation of the prosthesis. The nurse should instruct the patient to bend at the knees instead of the hips while brushing teeth or doing any other activity that requires bending. The other actions mentioned in the options are appropriate for a patient after hip arthroplasty.
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