A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

The patient may have paralytic ileus that could last 3-5 days

It is normal for all post-op patients not to have bowel sounds

The absence of bowel sounds is an abnormal finding

Document absent bowel sounds and notify the physician

Answer and Explanation

The Correct Answer is A

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

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Correct Answer is A

Explanation

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

A. Stop the treatment if the client's skin becomes red. B. Leave the pad in place for at least 40 min. C. Use safety pins to keep the pad in place. D. Set the pad's temperature to 42.2° C (108° F).

Correct Answer is A

Explanation

Choice A rationale: If the client's skin becomes red, the heat application should be stopped to prevent burns or skin damage.
Choice B rationale: Heat applications are generally recommended for 20-30 minutes, not at least 40 minutes, to avoid skin damage.
Choice C rationale: Safety pins should not be used to keep the heating pad in place, as they can damage the pad or cause injury to the client.
Choice D rationale: The temperature of the heating pad should be set to a comfortable and safe level, typically below 42.2° C (108° F).

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A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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