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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Correct Answer is B

Explanation

a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.

b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces

should not be present in the drainage appliance. This finding could indicate a complication and should be reported.

c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.

d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.

A. Low BP and low pulse rate B. Low BP and high pulse rate C. High BP and low pulse rate D. High BP and high pulse rate

Correct Answer is B

Explanation

a. Low BP and low pulse rate: In hypovolemic shock, there is a decrease in blood volume,

leading to low blood pressure. However, the body compensates by increasing the heart rate to maintain perfusion to vital organs.

b. Low BP and high pulse rate: This is indicative of hypovolemic shock. The low blood pressure results from decreased blood volume, while the high pulse rate is a compensatory mechanism to maintain cardiac output.

c. High BP and low pulse rate: This combination is not typical of hypovolemic shock. High blood pressure is not expected in the presence of decreased blood volume.

d. High BP and high pulse rate: While a high pulse rate is expected in hypovolemic shock, high blood pressure is not a characteristic finding.

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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 collecting data on a client who is two days postoperative following creation of an ileal conduit. The nurse should report which of the following findings?

Correct Answer is B

Explanation

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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?

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