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: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Correct Answer is A
Explanation
Choice A rationale: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.
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