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

Answer and Explanation

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

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 C

Explanation

Choice A rationale:

A colostomy is a surgical procedure that creates an opening in the colon (large intestine) to divert stool through the abdomen. While a colostomy can affect bowel function, it does not directly increase the risk of aspiration. This is because the colon is located further down the digestive tract and does not directly involve the airway.

Choice B rationale:

An ileostomy is a surgical procedure that creates an opening in the ileum (small intestine) to divert stool through the abdomen. Similar to a colostomy, an ileostomy does not directly increase the risk of aspiration because the ileum is also located further down the digestive tract and does not involve the airway.

Choice C rationale:

Enteral feedings, also known as tube feedings, involve delivering nutrients directly into the stomach or small intestine through a tube. Patients receiving enteral feedings through a nasogastric (NG) tube are at a significantly higher risk of aspiration for several reasons:

Impaired swallowing mechanisms: Many patients who require enteral feedings have impaired swallowing mechanisms, which can increase the risk of food or liquid entering the airway instead of the esophagus.

Tube placement: The NG tube itself can potentially irritate the esophagus or interfere with the normal closure of the upper esophageal sphincter, which can increase the risk of reflux and aspiration.

Feeding formula: Enteral feeding formulas are often thin and liquid-like, which can make them easier to aspirate than thicker liquids or solid foods.

Positioning: Patients receiving enteral feedings are often in a reclined position, which can make it easier for fluids to travel back up the esophagus and into the airway.

Choice D rationale:

A chest tube is a drainage tube inserted into the chest cavity to remove air or fluid. While a chest tube can affect respiratory function, it does not directly increase the risk of aspiration. This is because the chest tube drains fluid from the pleural space, which surrounds the lungs, and does not directly involve the airway or digestive tract.

A. Request NPO status for the client. B. Elevate the head of the bed to high Fowler’s. C. Measure the client’s temperature. D. Check the client’s respiratory rate and lung sounds.

Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

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 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

Correct Answer is C

Explanation

During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a patient who is a hospital employee. Several nurses have called seeking information about the patient. What action should the nurse take in response to inquiries from the nurses?

In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?

A nurse is caring for a patient who has acute kidney injury.The patient’s ABGs are: pH: 7.26, PaCO2: 30 mm Hg, HCO3: 14 mEq/L. Which of the following acid-base imbalances should the nurse identify the patient is experiencing?

With whom should a nurse share her password for access to the facility’s computer system?

A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.What type of drainage should the nurse report?

What triggers the afferent pathways, resulting in the sensation of pain?

A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client’s postoperative prescriptions, which include, “Clear liquids, advance diet as tolerated.” What action should the nurse take first?

A nurse is developing a care plan for a patient with pneumonia who requires chest percussion, vibration, and postural drainage. What should the nurse plan to do first?

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?