The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern?
Flank pain
Watery diarrhea
Fecal vomiting
Occult blood in the stool
The Correct Answer is C
Choice A rationale
Flank pain is not typically associated with a bowel obstruction. It is more commonly associated with kidney problems.
Choice B rationale
Watery diarrhea is not typically a symptom of bowel obstruction. Bowel obstruction usually causes constipation and inability to pass gas or stool.
Choice C rationale
Fecal vomiting is a serious symptom that can occur in severe cases of bowel obstruction. It indicates a significant blockage in the digestive tract that needs immediate medical attention.
Choice D rationale
Occult blood in the stool can be a symptom of many conditions, including bowel obstruction. However, it is not the most concerning symptom in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Observing mucous membranes for dryness can indicate dehydration.
Choice B rationale
Providing frequent oral care with moist swabs can help alleviate the discomfort of a dry mouth due to NPO status.
Choice C rationale
Offering the client small sips of water is not appropriate as the client is on a diet of nothing by mouth (NPO) except ice chips.
Choice D rationale
Increasing the rate of intravenous (IV) fluids can help prevent dehydration.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"C"}}
Explanation
• Increase fiber intake: This is nonessential at this time. While a high-fiber diet can help prevent future episodes of diverticulitis, it won’t help in the acute phase, especially when the client is unable to eat or drink without vomiting.
• CT of the abdomen with contrast: This is an anticipated action. A CT scan can help confirm the diagnosis of diverticulitis and assess the severity of the condition.
• Flexible sigmoidoscopy: This is an anticipated action. A flexible sigmoidoscopy can help visualize the diverticula and assess the extent of the inflammation.
• Change IV fluids to 0.9% sodium chloride with KCl: This is an anticipated action. The client is likely dehydrated due to vomiting and unable to take oral fluids, so IV hydration is necessary. The client’s potassium level is at the lower end of the normal range, so adding KCl to the IV fluids can help prevent hypokalemia.
• Type and crossmatch blood: This is an anticipated action. The client has a positive stool occult blood test and a lower than normal hemoglobin and hematocrit, suggesting that he may be experiencing bleeding. It’s important to have blood ready for a transfusion if necessary.
• Administer IV piperacillin-tazobactam: This is contraindicated. Piperacillin-tazobactam is a penicillin-based antibiotic, and the client has a known allergy to penicillin. Another class of antibiotics should be used. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.
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