A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

Normalized electrolytes.

Decreased nausea.

Passing of flatus.

Return of appetite.

Answer and Explanation

The Correct Answer is C

A.   Normalized electrolytes are important but do not specifically indicate gastrointestinal motility.
B.   Decreased nausea can be a sign of improvement but is less specific than passing flatus.
C.   Passing flatus indicates that there is movement of gas through the intestines, which is a direct sign of returning gastrointestinal motility.
D.   Return of appetite can occur for various reasons and is not as direct an indicator of GI motility as passing flatus.

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Correct Answer is A

Explanation

A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.

A. Report when hematuria becomes pink tinged. B. Restrict all physical activities. C. Use the incentive spirometer. D. Monitor urinary stream for decreased output.

Correct Answer is D

Explanation

A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.

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A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Correct Answer is A

Explanation

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

Correct Answer is D

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