A nurse is assessing a client who has a complete small bowel obstruction. Which of the following manifestations should the nurse expect? (Select all that apply.)

Urticaria

Vomiting

Distended abdomen

Fluid overload

Obstipation

Answer and Explanation

Correct Answer : B,C,E

A) Urticaria:
Urticaria, or hives, is a skin reaction characterized by itchy, raised welts. It is not typically associated with a small bowel obstruction, which primarily affects the gastrointestinal system rather than the skin.

B) Vomiting:
Vomiting is a common symptom of a complete small bowel obstruction. It occurs due to the blockage in the intestines, which prevents the passage of contents, leading to nausea and vomiting as the body tries to expel the obstruction.

C) Distended abdomen:
A distended abdomen is expected in cases of small bowel obstruction. The blockage causes a buildup of gas and fluids, leading to abdominal swelling and distention as the normal passage of intestinal contents is impeded.

D) Fluid overload:
Fluid overload is not a typical manifestation of a small bowel obstruction. Instead, dehydration and electrolyte imbalances are more likely due to vomiting and the inability to absorb fluids and nutrients properly.

E) Obstipation:
Obstipation, or severe constipation with an inability to pass stool or gas, is a key sign of a complete small bowel obstruction. The obstruction prevents the normal movement of intestinal contents, leading to a cessation of bowel movements.

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Correct Answer is B

Explanation

A) Decreased deep-tendon reflexes: Decreased deep-tendon reflexes can indicate hyperkalemia, which occurs when potassium levels are too high. This is not a sign of effective potassium chloride supplementation for hypokalemia, as it suggests an imbalance in the opposite direction.

B) Regular heart rhythm: A regular heart rhythm is a key indicator that potassium levels are within the normal range. Potassium is crucial for proper cardiac function, and maintaining an adequate level helps prevent arrhythmias and supports effective heart rhythms.

C) Hypoactive bowel sounds: Hypoactive bowel sounds can be associated with various conditions, including electrolyte imbalances like hypokalemia. However, the presence of hypoactive bowel sounds does not directly indicate that potassium chloride supplementation is effective.

D) Respiratory rate 10/min: A respiratory rate of 10/min is below the normal range and can be a sign of respiratory depression or other issues. This finding does not relate to the effectiveness of potassium chloride supplements in treating hypokalemia.

A. "I will expect to have to strain while having a bowel movement." B. "I'll plan to restrict my fluid intake to 1 liter per day." C. "I might have the urge to urinate while I have the catheter in place." D. "I'll keep my leg flexed if the catheter is taped to my leg."

Correct Answer is C

Explanation

A) "I will expect to have to strain while having a bowel movement":
Straining during bowel movements should be avoided as it can increase abdominal pressure and strain on the surgical site, potentially leading to complications such as bleeding or increased discomfort.

B) "I'll plan to restrict my fluid intake to 1 liter per day":
Fluid restriction is not typically advised after a transurethral resection of the prostate (TURP). Adequate fluid intake is important to help flush the bladder and reduce the risk of blood clots and urinary tract infections.

C) "I might have the urge to urinate while I have the catheter in place":
It is common for clients to feel the urge to urinate while a catheter is in place due to the pressure of the catheter on the bladder neck. This statement indicates an understanding of the postoperative experience and normal sensations.

D) "I'll keep my leg flexed if the catheter is taped to my leg":
Keeping the leg flexed is not necessary for catheter management. The catheter should be securely taped to the leg to prevent movement and minimize discomfort, but the position of the leg is not a critical factor in its management.

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A nurse is assessing a client who has a complete small bowel obstruction. Which of the following manifestations should the nurse expect? (Select all that apply.)

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