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 C
Explanation
Choice A rationale:
Recapping needles is a dangerous practice that significantly increases the risk of needlestick injuries.
The act of recapping involves directing the sharp end of the needle towards one's hand, creating a high likelihood of accidental puncture.
Even experienced healthcare professionals are susceptible to needlestick injuries during recapping.
Wastebaskets are not designed for the safe disposal of sharps and can easily be punctured, leading to potential exposure to bloodborne pathogens.
Choice B rationale:
While it is true that needles should not be recapped on ABG specimens, this option does not address the broader issue of safe needle disposal in general.
Focusing solely on ABG specimens could lead to the misconception that recapping is acceptable for other types of needles.
Choice D rationale:
Breaking needles in half is not recommended as a standard practice for needle disposal.
This action can create sharp fragments that are difficult to handle and can still cause injuries.
Sharps disposal containers are designed to safely contain intact needles and should be used as the primary method of disposal.
Choice C rationale:
Placing uncapped needles directly into a puncture-proof container is the safest and most recommended practice for needle disposal.
These containers are specifically designed to prevent needlestick injuries by shielding the sharps from accidental contact. They are typically made of hard plastic or metal and are clearly labeled for biohazard waste.
Using puncture-proof containers consistently for all needle disposal significantly reduces the risk of needlestick injuries among healthcare workers.
Correct Answer is C
Explanation
Choice A rationale:
Irreversible shock is the final stage of shock, where the body's compensatory mechanisms have failed, and damage to vital organs is irreversible. This stage is characterized by:
Profound hypotension (systolic blood pressure persistently below 60 mmHg) Severely altered mental status (unresponsiveness or coma)
Widespread organ failure (kidney failure, liver failure, respiratory failure) Lack of response to aggressive fluid resuscitation and vasopressor therapy
The patient in the question does not exhibit all of these signs and symptoms, particularly the profound hypotension and irreversible organ failure. Therefore, irreversible shock is not the most likely stage.
Choice B rationale:
End-organ dysfunction is a stage of shock where inadequate tissue perfusion has begun to cause damage to vital organs. This stage is characterized by:
Hypotension that may respond to fluid resuscitation
Signs of organ dysfunction, such as decreased urine output, altered mental status, or respiratory distress
The patient in the question does have some signs of organ dysfunction, such as confusion and crackles on lung auscultation. However, the hypotension is not as severe as typically seen in end-organ dysfunction shock, and there is no mention of other organ dysfunction like decreased urine output. Therefore, end-organ dysfunction is not the most likely stage.
Choice C rationale:
Early reversible shock is the initial stage of shock, where the body's compensatory mechanisms are still able to maintain blood pressure and organ perfusion. This stage is characterized by:
Mild to moderate hypotension Tachycardia
Cool, clammy skin Narrowed pulse pressure Restlessness or anxiety
The patient in the question presents with all of these signs and symptoms, making early reversible shock the most likely stage.
Choice D rationale:
Preshock is a state of impending shock, where the body's compensatory mechanisms are activated but not yet fully effective. This stage is characterized by:
Normal or slightly low blood pressure Tachycardia
Cool, clammy skin Restlessness or anxiety
The patient in the question has hypotension, which is not consistent with preshock. Therefore, preshock is not the correct stage.
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