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. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.

b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia

c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.

d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.

A. Instruct the client to tilt her head back when she swallows. B. Add thickener to fluids. C. Place food on the left side of the client's mouth. D. Serve food at room temperature.

Correct Answer is B

Explanation

a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and

swallowing difficulties.

b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.

c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.

d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.

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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

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