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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.
Correct Answer is A
Explanation
Choice A rationale: Voiding and discarding the urine is the first step in a 24-hour urine collection to ensure that the collection starts with a fresh specimen.
Choice B rationale: Adding the first voiding to the specimen is not the correct initial step.
Choice C rationale: Keeping the urine warm during collection is important, but it is not the first step in the process.
Choice D rationale: Beginning the collection at a specific time is part of the process but not the initial step.
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