A nurse is caring for a patient on the third day following abdominal surgery.
The nurse notes the absence of bowel sounds, abdominal distention, and the patient has not passed any flatus. Which postoperative complication is the patient likely experiencing?
Paralytic ileus
Incisional infection
Fecal impaction
Health care-associated Clostridium difficile
The Correct Answer is A
Choice A rationale:
Paralytic ileus is a common postoperative complication that occurs when the normal movement of the intestines (peristalsis) is slowed or stopped. This can lead to a buildup of gas and fluids in the intestines, causing abdominal distention, nausea, vomiting, and constipation. The absence of bowel sounds, abdominal distention, and the inability to pass flatus are all classic signs of paralytic ileus.
Here are some of the factors that can contribute to paralytic ileus: Manipulation of the intestines during surgery
Anesthesia
Pain medications, especially opioids Electrolyte imbalances
Dehydration
Underlying medical conditions, such as diabetes or kidney disease Treatment for paralytic ileus typically involves:
Resting the bowel by not eating or drinking anything by mouth
Using a nasogastric (NG) tube to suction out gas and fluids from the stomach Providing intravenous (IV) fluids and electrolytes
Encouraging early ambulation
Using medications to stimulate bowel movement, such as metoclopramide or erythromycin
Choice B rationale:
Incisional infection is an infection of the surgical wound. It would typically present with redness, warmth, swelling, and pain at the incision site. The patient may also have a fever. While incisional infections can occur after abdominal surgery, they are not typically associated with the absence of bowel sounds, abdominal distention, and the inability to pass flatus.
Choice C rationale:
Fecal impaction is a severe form of constipation in which a large, hard mass of stool becomes trapped in the rectum. It can cause abdominal pain, bloating, and difficulty passing stool. However, it is not typically associated with the absence of bowel sounds or abdominal distention.
Choice D rationale:
Health care-associated Clostridium difficile (C. difficile) is a bacterial infection that can cause severe diarrhea, abdominal pain, and cramping. It is often associated with antibiotic use. While C. difficile can occur after abdominal surgery, it is not typically associated with the absence of bowel sounds, abdominal distention, and the inability to pass flatus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:
Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.
Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.
Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.
Blood or secretions in the airway: These can obstruct the airway and cause stridor.
It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:
Oxygen therapy: This can help to improve the patient's breathing.
Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.
Correct Answer is C
Explanation
Choice A rationale:
Avoiding crossing legs at the knees is a correct practice for people with PVD. It helps to prevent constriction of blood flow in the legs. When legs are crossed, pressure is applied to the veins in the lower leg, which can impede blood flow. This can lead to several problems, including:
Increased risk of blood clots Worsening of swelling in the legs Increased pain and discomfort Potential skin damage
Reinforcing this practice with the client is important.
Choice B rationale:
Not going barefoot is also a correct practice for people with PVD. It helps to protect the feet from injuries and infections. People with PVD may have reduced sensation in their feet, making them more susceptible to injuries they may not notice. Additionally, PVD can impair wound healing, so even minor injuries can become serious problems.
Reinforcing this practice with the client is important.
Choice C rationale:
Using a thermometer to check bath water temperature is not directly relevant to PVD management. While it's generally a good safety practice to avoid excessively hot water, which can burn the skin, it's not specifically related to the blood flow issues associated with PVD.
This statement indicates a need for further teaching to focus on PVD-specific self-care measures.
Choice D rationale:
Wearing stockings with elastic tops is generally recommended for people with PVD. These stockings, often referred to as compression stockings, help to improve blood flow in the legs by applying gentle pressure. This can help to reduce swelling, pain, and the risk of blood clots.
Reinforcing this practice with the client is important.
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