he nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Paralytic ileus

Incisional infection

Fecal impaction

Health care-associated Clostridium difficile

Answer and Explanation

The Correct Answer is A

A. Paralytic ileus: Paralytic ileus occurs when intestinal motility is temporarily lost after surgery. Clinical findings include absent bowel sounds, distention, and no flatus or stool, requiring monitoring and supportive care.

B. Incisional infection: Infection would present with erythema, warmth, purulent drainage, or fever rather than absent bowel sounds or lack of flatus.

C. Fecal impaction: Fecal impaction usually occurs in the lower bowel, often causing hard stools and discomfort. It is unlikely on postoperative day 3 with absent bowel sounds throughout the abdomen.

D. Health care–associated Clostridium difficile: C. difficile infection typically causes diarrhea, abdominal cramping, and fever, not absence of bowel sounds or flatus.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Diarrhea:Lactulose draws water into the bowel and increases stool frequency; diarrhea is a common intended/adverse effect and can lead to dehydration and electrolyte imbalances.

B. Peripheral edema:Peripheral edema is related to fluid overload/albumin shifts in cirrhosis, not a typical adverse effect of lactulose.

C. Dry mouth:Dry mouth is not a common adverse effect of lactulose; GI effects (bloating, flatulence, diarrhea) are more likely.

D. Headache:Headache is not a characteristic adverse effect of lactulose therapy.

A. Drinking orange juice regularly B. Sleeping on a large wedge-style pillow C. Consuming low-fat meats D. Eating dinner early in the evening

Correct Answer is A

Explanation

A. Drinking orange juice regularly:Citrus juices are acidic and can relax the lower esophageal sphincter and directly irritate the esophagus, worsening reflux and heartburn.

B. Sleeping on a large wedge-style pillow:Sleeping upright or with head elevated reduces nighttime reflux by using gravity to keep gastric contents in the stomach - this is helpful, not a contributor.

C. Consuming low-fat meats:Low-fat meats decrease gastric emptying delay related to fatty meals and reduce reflux risk; they are generally not a contributing factor.

D. Eating dinner early in the evening:Eating earlier (allowing 2–3 hours before lying down) reduces reflux at night; this is protective rather than contributory.

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he nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

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A nurse is reinforcing teaching a client who has peptic ulcer disease and is starting therapy with sucralfate. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

A nurse is caring for a client who is 2 days postoperative from abdominal surgery. The client reports discomfort from abdominal distension and flatus. Which of the following suggestions should the nurse include?