A nurse on a medical-surgical unit is caring for four patients who are 24 to 36 hours postoperative. Which of the following surgical procedures places the patient at risk for deep-vein thrombosis?

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 A rationale
Providing information is a communication technique where the nurse gives the patient factual and relevant information. In this scenario, the nurse is not providing information but rather seeking to understand the patient’s feelings.
Choice B rationale
Summarizing is a communication technique where the nurse reviews the main points of the conversation to ensure understanding. In this scenario, the nurse is not summarizing the conversation but rather seeking to understand the patient’s feelings.

Choice C rationale
Clarification is a communication technique where the nurse seeks to understand the patient’s message by asking for more information or for elaboration on a point. In this scenario, the nurse is using clarification by restating the patient’s concern in a different way to confirm their understanding.
Choice D rationale
Confrontation is a communication technique where the nurse addresses observed discrepancies or conflicts in the patient’s behavior or communication. In this scenario, the nurse is not confronting the patient but rather seeking to understand their feelings.