A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss.
The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

Choice C rationale
In the context of suspected acute pancreatitis, an increase in serum amylase is one of the key laboratory findings. Pancreatitis is associated with inflammation of the pancreas, which can result in the release of digestive enzymes such as amylase and lipase into the bloodstream.
Therefore, elevated levels of these enzymes are often used as markers for acute pancreatitis.
Choice A rationale
Decreased serum lipase is not typically associated with acute pancreatitis. In fact, an increase in serum lipase is more commonly seen in acute pancreatitis. Lipase is a digestive enzyme produced by the pancreas, and its levels in the blood can rise when the pancreas is inflamed.
Choice B rationale
Increased serum calcium is not typically associated with acute pancreatitis. While hypercalcemia, or high calcium levels, can be a cause of pancreatitis, it is not a typical finding in the blood tests of patients with acute pancreatitis.
Choice D rationale
Decreased white blood cell (WBC) count is not typically associated with acute pancreatitis. In fact, an increase in WBC count can sometimes be seen in acute pancreatitis due to the body’s inflammatory response to the condition. Hypothyroidism Explore