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 C
Explanation
Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.
By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.
Correct Answer is C
Explanation
Nitroprusside is a potent vasodilator medication used to rapidly reduce blood pressure in hypertensive emergencies. Its primary action is to dilate blood vessels, leading to a decrease in systemic vascular resistance and subsequent reduction in blood pressure.
Monitoring the client's blood pressure is crucial during the administration of nitroprusside to ensure that the medication is achieving the desired effect and that blood pressure is being appropriately controlled. The nurse will assess blood pressure frequently to adjust the infusion rate and titrate the medication to achieve the desired therapeutic effect while avoiding hypotension or other adverse effects.
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