A new nurse is working in a hospital.
Which of the following actions by the nurse is NOT related to one of the National Patient Safety Goals?

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made.

Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown. Choice A is wrong because red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anemia.

Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia. Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia.

Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 gramsper deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.