Nurs-172 Exam 5 (A+ GUARANTEED)

The nurse performs a detailed assessment of the abdomen of a client with a possible bowel obstruction, knowing that a manifestation of an obstruction in the large intestine is (Select all that apply) (There are 2 correct answers) A. a largely distended abdomen. B. diarrhea that is loose or liquid. C. persistent, colicky abdominal pain. D. profuse vomiting that relieves abdominal pain. correct answers A. a largely distended abdomen. C. persistent, colicky abdominal pain. Rationale: Persistent, colicky abdominal pain is seen with lower intestinal obstruction. Abdominal distention is markedly increased in lower intestinal obstructions. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation. The nurse is caring for a patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which of the following types of bowel sounds that is consistent with the patient's clinical picture? (Select one answer) A. Low pitched and rumbling above the area of obstruction B. High pitched and hypoactive below the area of obstruction C. Low pitched and hyperactive below the area of obstruction D. High pitched and hyperactive above the area of obstruction correct answers D. High pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent. The nurse is preparing to insert a nasogastric tube into a patient with an abdominal mass and suspected bowel obstruction. The patient asks the nurse why this procedure is necessary. Which of the following responses is most appropriate? (Select one answer) A. "The tube will help to drain the stomach contents and prevent further vomiting." B. "The tube will push past the area that is blocked, and thus help to stop the vomiting." C. "The tube is just a standard procedure before many types of surgery to the abdomen." D. "The tube will let us measure your stomach contents, so that we can plan what type of IV fluid replacement would be best." correct answers A. "The tube will help to drain the stomach contents and prevent further vomiting." The nasogastric tube is used to decompress the stomach by draining stomach contents, and thereby prevent further vomiting.