NCLEX PN Practice Test with NGN Practice Question
Potential Intervention, Anticipated, Unanticipated,, Radio
Scenario/Extract:
The nurse in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.
The nurse is assisting the registered nurse with developing the plan of care. For each potential intervention, click to specify the intervention is anticipated or unanticipated for the care of the client.
Correct Answer: A: Anticipated, B: Unanticipated, C: Unanticipated, D: Anticipated, E: Anticipated, F: Unanticipated
Rationale: A rectal tube may help decompress the bowel in ileus. Advancing to a regular diet is contraindicated until bowel function returns. Strict bed rest is not necessary; ambulation is encouraged. Measuring abdominal girth monitors distension. Nonopioid pain medication is appropriate for pain management. Cold packs are not standard for abdominal pain in ileus and may not be effective.
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