The 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

Health care-associated Clostridium difficile

Fecal impaction

Answer and Explanation

The Correct Answer is A

A. Paralytic ileus is a common postoperative complication characterized by the absence of bowel sounds, abdominal distention, and failure to pass flatus due to a lack of intestinal peristalsis.

B. Incisional infection would typically present with localized symptoms such as redness, warmth, and purulent drainage at the surgical site, not generalized abdominal distention and lack of bowel sounds.

C. Health care-associated Clostridium difficile infection usually presents with diarrhea, not an absence of bowel sounds or abdominal distention.

D. Fecal impaction is more likely to cause localized pain and possible leakage of liquid stool, rather than complete absence of bowel sounds and severe distention.

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Correct Answer is B

Explanation

A. Third spacing involves the abnormal accumulation of fluid in extracellular spaces and is more commonly associated with hypovolemic or distributive shock, not obstructive shock.

B. Cardiac tamponade is a classic cause of obstructive shock, where the accumulation of fluid in the pericardial sac compresses the heart, leading to decreased cardiac output and obstructed blood flow.

C. Cardiomyopathy is a disease of the heart muscle that can lead to heart failure but is typically associated with cardiogenic shock, not obstructive shock.

D. A ruptured aneurysm would most likely cause hypovolemic shock due to blood loss, not obstructive shock.

A. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." B. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart" C. "Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration." D. "Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath."

Correct Answer is B

Explanation

A. Nitroglycerin does not dissolve blood clots; it works by dilating blood vessels to increase blood flow.

B. Nitroglycerin dilates the coronary arteries, increasing oxygen delivery to the heart muscle and relieving angina, which is caused by reduced blood flow to the heart.

C. Nitroglycerin is not used to relieve nausea or prevent vomiting; it is used primarily to manage chest pain.

D. Nitroglycerin is not a bronchodilator; it does not affect the airways directly but rather improves blood flow to the heart.

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The 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 assisting in providing care for a client who has obstructive shock. Which of the following diagnoses should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who is newly-admitted and has angina. The client asks the nurse, "Why am I taking nitroglycerin?" Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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This surgery is a more extensive procedure than a biopsy. It usually requires opening a body cavity to diagnose and to find out the extent of a disease process.