On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?
Administering a PRN cathartic.
Reducing IV fluid to a keep-open rate.
Advancing diet to full liquids.
Insertion of a nasogastric tube.
The Correct Answer is D
Choice A reason: A cathartic is contraindicated, as pain, distension, and absent bowel sounds suggest postoperative ileus or obstruction, where peristalsis is impaired. Cathartics risk perforation. A nasogastric tube decompresses the bowel, addressing gastrointestinal stasis, preventing complications like vomiting or rupture.
Choice B reason: Reducing IV fluids does not address pain, distension, or absent bowel sounds, indicating ileus or obstruction. Fluids maintain hydration, but nasogastric tube insertion relieves bowel pressure from gas and fluid, restoring function, making fluid reduction ineffective for this postoperative complication.
Choice C reason: Advancing to liquids is inappropriate with absent bowel sounds and distension, indicating ileus, risking vomiting or aspiration. A nasogastric tube removes gastric contents, allowing bowel recovery. Oral intake worsens obstruction, making this contraindicated compared to decompression for safe recovery.
Choice D reason: Nasogastric tube insertion is critical for pain, distension, and absent bowel sounds, suggesting postoperative ileus or obstruction. It decompresses the stomach, removing gas and fluid, reducing pressure and preventing perforation. This addresses the pathophysiological basis of impaired motility, ensuring safe postoperative recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Acetaminophen reduces pain but is secondary to preventing infection and bleeding with petrolatum dressings. Dressings are the immediate post-circumcision priority to protect the surgical site, per circumcision care and infection control protocols in neonatal nursing practice.
Choice B reason: Wrapping in blankets maintains warmth but does not address the surgical site’s immediate needs. Petrolatum dressings prevent infection and adhesion, critical post-circumcision. Warmth is secondary, per circumcision care and neonatal thermoregulation standards in nursing practice.
Choice C reason: Offering a glucose-dipped pacifier soothes but does not protect the circumcision site from infection or bleeding. Petrolatum dressings are the priority to ensure healing and comfort, per circumcision care and postoperative pain management standards in neonatal nursing practice.
Choice D reason: Applying petrolatum gauze dressings prevents infection, promotes healing, and reduces adhesion of the circumcision site to diapers. This is the priority intervention to protect the surgical wound, per evidence-based circumcision care and infection control protocols in neonatal nursing practice.
Correct Answer is C
Explanation
Choice A reason: Baked potato with skin is high in potassium (about 900 mg), unsuitable for CKD, where impaired renal excretion risks hyperkalemia, causing cardiac arrhythmias. White rice is low-potassium, aligning with dietary restrictions, demonstrating understanding of the need to limit potassium intake in renal disease.
Choice B reason: Orange juice contains high potassium (about 500 mg per cup), dangerous in CKD, as reduced glomerular filtration increases hyperkalemia risk, affecting cardiac conduction. White rice, with minimal potassium, complies with restrictions, indicating the client’s understanding of safe dietary choices for kidney function.
Choice C reason: White rice is low in potassium (about 50 mg per cup), appropriate for CKD, where the kidneys cannot excrete excess potassium, risking hyperkalemia and arrhythmias. Choosing white rice shows the client understands the low-potassium diet, supporting safe management of renal disease and electrolyte balance.
Choice D reason: Banana smoothie is high in potassium (about 400 mg per banana), contraindicated in CKD, where hyperkalemia risks cardiac instability due to poor renal clearance. White rice, low in potassium, reflects dietary compliance, demonstrating the client’s understanding of restrictions to prevent electrolyte imbalances.
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