A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

High-pitched bowel sounds

Abdominal bruit

Bruising on the flank area

Coffee-ground emesis

Answer and Explanation

The Correct Answer is A

A) High-pitched bowel sounds: High-pitched bowel sounds, also known as "tinkling" sounds, are characteristic of mechanical bowel obstructions. These sounds are created by the intestines as they try to move contents past the obstruction, resulting in increased peristaltic activity. In the case of intussusception, where one segment of the intestine telescopes into another, the obstruction can cause these distinctive high-pitched sounds due to the narrowing of the bowel lumen.

B) Abdominal bruit: An abdominal bruit is a swishing sound heard over the abdomen, usually indicating turbulent blood flow through narrowed arteries. It is commonly associated with vascular conditions such as atherosclerosis or renal artery stenosis. It is not related to bowel obstruction, as bowel sounds in obstruction cases are generally due to changes in peristaltic activity rather than blood flow.

C) Bruising on the flank area: Bruising on the flank area, known as Grey Turner's sign, is typically seen in conditions involving retroperitoneal hemorrhage, such as severe pancreatitis or trauma. It is not a symptom of bowel obstruction. Bowel obstruction symptoms generally relate to the gastrointestinal tract and include abdominal pain, distension, and altered bowel sounds.

D) Coffee-ground emesis: Coffee-ground emesis is vomit that appears like coffee grounds, indicating the presence of partially digested blood. This is a sign of upper gastrointestinal bleeding, often due to peptic ulcers or gastritis. In mechanical bowel obstruction, vomiting is more likely to contain bile (bilious vomiting) and may occur if the obstruction is high in the small intestine. The appearance of coffee-ground emesis is not typical for bowel obstructions and indicates a different type of gastrointestinal issue.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) "You will be allowed to drive yourself home within 6 hours following the procedure."This statement is incorrect. After an esophagogastroduodenoscopy (EGD), the patient is typically sedated, and the sedation can affect their alertness, coordination, and judgment. It is generally recommended that patients arrange for someone else to drive them home. It is unsafe for the patient to drive themselves after sedation, even if they feel alert. The nurse should instruct the client to have someone accompany them to the procedure and drive them home afterward.

B) "You might experience a hoarse voice for several days following the procedure."This statement is correct. A hoarse voice is a common and expected side effect after an esophagogastroduodenoscopy, as the procedure involves passing a flexible tube (endoscope) through the mouth and throat. The endoscope may cause irritation to the vocal cords or the lining of the throat, leading to a hoarse voice that can last for a few days. This is a normal, transient effect and should be explained to the patient in advance so they are not alarmed.

C) "You can have a clear liquid diet for breakfast prior to the procedure."This statement is incorrect. For most procedures like EGD, patients are typically instructed to fast for at least 6 to 8 hours prior to the procedure to ensure the stomach is empty. Having food or liquids before the procedure may increase the risk of aspiration or interfere with the examination. The nurse should educate the client to follow fasting instructions and avoid consuming any food or liquids, including clear liquids, as per the healthcare provider's guidelines.

D) "You should not take any of your routine medications until after the procedure is complete."

This statement is generally incorrect. Many patients are instructed to continue taking routine medications, especially if they are vital for managing chronic conditions, unless otherwise directed by the healthcare provider. In some cases, medications such as anticoagulants, aspirin, or certain blood pressure medications may need to be withheld temporarily before the procedure. However, the nurse should clarify with the healthcare provider which medications the client should stop or continue taking before the procedure. The patient should not withhold medications on their own without proper guidance.

A. Protective environment B. Airborne precautions C. Contact precautions D. Droplet precautions

Correct Answer is D

Explanation

A) Protective environment
This type of isolation is used for clients with weakened immune systems to protect them from infections. It is not necessary for pertussis, which requires droplet precautions to prevent spread.

B) Airborne precautions
These are used for diseases that are spread through tiny droplets that remain in the air, such as tuberculosis. Pertussis spreads through larger respiratory droplets, not lingering in the air, so airborne precautions are not needed.

C) Contact precautions
These are used for infections spread by direct touch or contact with surfaces. Pertussis primarily spreads through respiratory droplets rather than direct contact, making contact precautions unnecessary.

D) Droplet precautions
Droplet precautions are appropriate for pertussis, as it spreads via respiratory droplets when an infected person coughs or sneezes. This involves wearing masks and maintaining distance to prevent transmission.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has peptic ulcer disease and is scheduled for an esophagogastroduodenoscopy the next morning. Which following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is planning care for a client who has the communicable disease pertussis. Which of the following isolation guidelines should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is providing discharge planning for a young adult client who is postoperative following a myringotomy. Which of the following information should the nurse include in the discharge planning?

A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has the communicable disease influenza. Which of the following isolation precautions should the nurse take?

A nurse is assessing the health literacy of an older adult client who has type 2 diabetes mellitus. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who had a laparoscopic cholecystectomy for cholecystitis. Which of the following information should the nurse include in the teaching?

A nurse is teaching a client who has pneumonia about the use of an incentive spirometer. Which of the following instructions should the nurse Include?

A nurse is providing teaching to a client who has severe peripheral arterial vascular disease. Which of the following information should the nurse include?

A nurse is examining a skin infection on a client's lower left leg. Findings include edema, erythema, tenderness, and the client reports pain. The nurse should identify that these findings indicate which of the following?