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","B"]

Explanation

Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.

A. Unintentional closed wound B. Intentional closed wound C. Intentional open wound D. Unintentional open wound

Correct Answer is D

Explanation

Choice A rationale: Unintentional closed wounds involve blunt force trauma but do not typically result in jagged edges with muscle tissue visible.
Choice B rationale: Intentional closed wounds are typically surgical incisions and do not present with jagged edges and visible muscle tissue.
Choice C rationale: Intentional open wounds are typically surgical incisions, not the result of a biking accident.
Choice D rationale: Unintentional open wounds result from accidents and can present with jagged edges and visible tissue.

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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

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

Correct Answer is ["A","B"]

Explanation

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

Correct Answer is D

Explanation

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic. Isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

When moving a client up in bed with the assistance of another caregiver, the nurse should:

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?