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 A

Explanation

A. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.

B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.

C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.

D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.

A. Pleural friction rub B. Fine rales C. Rhonchi D. Expiratory wheeze

Correct Answer is D

Explanation

a. Pleural friction rub: Pleural friction rub is a grating sound heard during inspiration and

expiration and is associated with inflammation of the pleura. It is not typically associated with asthma exacerbation.

b. Fine rales: Fine rales (crackles) are usually heard during inspiration and can be associated with conditions such as pneumonia or pulmonary fibrosis. They are not the typical lung sounds in

asthma exacerbation.

c. Rhonchi: Rhonchi are low-pitched wheezes heard during inspiration and expiration. While they can be associated with asthma, expiratory wheezes are more specific to asthma

exacerbation.

d. Expiratory wheeze: Expiratory wheezes are high-pitched, musical sounds heard during

expiration and are characteristic of asthma exacerbation. They result from narrowed airways and increased airway resistance.

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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

nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should thenurse make?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Correct Answer is D

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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