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?

Incisional infection

Paralytic ileus

Health care-associated Clostridium difficile

Fecal impaction

Answer and Explanation

The Correct Answer is B

b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.

c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.

d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the

rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.

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Free Nursing Study Resources

Correct Answer is A

Explanation

a. Three to seven days after menses stops: Performing BSE a few days after menstruation allows the breasts to return to a more baseline state, reducing the influence of hormonal changes on

breast tissue.

b. On the same day every month: Hormonal changes during the menstrual cycle can affect breast tissue, and performing BSE on the same day every month may not provide consistent conditions for examination.

c. Prior to the beginning of menses: Hormonal changes before menstruation can lead to breast tenderness and changes, potentially affecting the accuracy of the examination.

d. On the second day of menstruation: Hormonal changes and potential breast tenderness during the early days of menstruation may not be the optimal time for BSE.

A. Bile B. Lipids C. Blood D. Bacteria

Correct Answer is C

Explanation

a. Bile: The guaiac test is not used to detect bile in the stool.

b. Lipids: The guaiac test is not used to detect lipids in the stool.

c. Blood: The guaiac test, also known as the fecal occult blood test (FOBT), is used to detect hidden (occult) blood in the stool. It is commonly used as a screening test for colorectal cancer.

d. Bacteria: The guaiac test is not used to detect bacteria in the stool.

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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 reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

Correct Answer is A

Explanation

A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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