Nokea
Paralytic ileus may occur as a postoperative complication. Which of the following patients would you be most concerned about the development of paralytic ileus?
- A. Kim, a 27-year-old postlaparoscopic appendectomy.
- B. Joyce, a 39-year-old post–open right hemicolectomy.
- C. Nancy, a 56-year-old postmediastinoscopy.
- D. John, a 47-year-old post–total joint replacement.
Correct Answer: B
Rationale: Paralytic ileus is more common after abdominal surgeries, particularly those involving bowel manipulation, such as an open right hemicolectomy. Joyce is at the highest risk due to the nature of her surgery.
You may also like to solve these questions
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.
A client with chronic obstructive pulmonary disease is receiving dietary teaching from a nurse. Which of the following instructions should the nurse include?
- A. Eat 3 balanced meals each day.
- B. Limit fluid intake with meals.
- C. Reduce sodium intake.
- D. Take a bronchodilator 1 hour before eating.
Correct Answer: B
Rationale: The correct answer is B: Limit fluid intake with meals. This instruction is important for a client with COPD because excessive fluid intake during meals can lead to increased stomach distention, which can worsen breathing difficulties. By limiting fluid intake with meals, the client can reduce the risk of feeling bloated and experiencing shortness of breath.
A: Eating 3 balanced meals each day is generally a good recommendation, but it does not specifically address the needs of a client with COPD.
C: Although reducing sodium intake can be beneficial for managing COPD, it is not as directly related to dietary considerations during meals.
D: Taking a bronchodilator 1 hour before eating is not a dietary instruction and does not address the issue of fluid intake during meals.
Which task should be delegated to the LPN/LVN?
- A. Gently cleanse the amputated digits with Betadine solution
- B. Place the amputated digits directly into ice slurry
- C. Wrap the amputated digits in sterile gauze moistened with saline
- D. Store the amputated digits in a solution of sterile normal saline
Correct Answer: C
Rationale: Wrapping the digits in sterile gauze moistened with saline is a simple task that can be performed by an LPN/LVN.
End-of-life palliative nursing care involves
- A. Constant assessment for changes in physiologic functioning.
- B. Administering large doses of analgesics to keep the patient sedated.
- C. Providing as little physical care as possible to prevent disturbing the patient.
- D. Encouraging the patient and family members to verbalize their feelings of sadness
Correct Answer: D
Rationale: Emotional and psychological support for both the patient and family is crucial in palliative care, helping them process feelings and find closure.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.