Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action for the nurse to take?
Provide meticulous oral care and allow the patient to have ice chips for dry mouth.
Notify the surgeon immediately and prepare the patient for emergency surgery.
Keep the patient NPO and document the finding in the patient’s medical record.
Allow the patient to have clear liquids as tolerated to help bowel function return.
The Correct Answer is C
Choice A rationale:
While providing meticulous oral care and allowing ice chips for dry mouth can promote comfort, it does not address the primary concern of absent bowel sounds.
Ice chips could potentially stimulate bowel activity, but this is not a reliable or recommended method for managing absent bowel sounds in the immediate postoperative period.
It's essential to prioritize actions that assess and address the potential causes of absent bowel sounds, as they can indicate serious complications.
Choice B rationale:
Notifying the surgeon immediately and preparing for emergency surgery is not the appropriate first course of action in this situation.
Emergency surgery would be considered only if there were clear signs of a life-threatening complication, such as bowel perforation or peritonitis.
These complications would typically present with additional symptoms such as severe abdominal pain, fever, and hemodynamic instability.
Absent bowel sounds alone, without other concerning signs, do not warrant immediate surgical intervention.
Choice D rationale:
Allowing the patient to have clear liquids as tolerated is not appropriate when bowel sounds are absent. Introducing oral intake before bowel function has returned can increase the risk of nausea, vomiting, and aspiration.
It's crucial to wait for the return of bowel sounds before initiating oral intake to ensure proper digestion and minimize complications.
Choice C rationale:
Keeping the patient NPO (nothing by mouth) is the most appropriate action when bowel sounds are absent after major abdominal surgery.
This allows the bowel to rest and recover from the surgical manipulation.
It also prevents potential complications such as aspiration and nausea/vomiting that could arise from premature oral intake.
Documenting the absence of bowel sounds in the patient's medical record is essential for communication among healthcare providers and for monitoring the patient's progress.
This documentation provides a clear record of the patient's clinical status and facilitates appropriate decision-making regarding further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A lactose-free diet does not contraindicate acupuncture therapy. Lactose intolerance is a digestive condition that does not affect blood clotting or the ability to receive acupuncture safely.
Acupuncture needles are very fine and do not typically cause bleeding. Even if minor bleeding occurs, it is not a concern for individuals without bleeding disorders.
Therefore, a lactose-free diet does not pose a risk for acupuncture.
Choice B rationale:
Thrombocytopenia is a condition characterized by a low platelet count. Platelets are essential for blood clotting. Acupuncture involves the insertion of needles into the skin. This can cause minor bleeding, even when performed correctly.
In individuals with thrombocytopenia, even minor bleeding can be difficult to control and may lead to excessive bruising or hematoma formation.
Therefore, thrombocytopenia is a contraindication to acupuncture therapy due to the increased risk of bleeding complications.
Choice C rationale:
Herniated lumbar disks are a common condition that can cause back pain. Acupuncture is often used to treat back pain, including pain caused by herniated disks.
Studies have shown that acupuncture can be effective in reducing pain and improving function in patients with herniated disks.
Therefore, the presence of herniated lumbar disks does not contraindicate acupuncture therapy.
Choice D rationale:
Latex and strawberry allergies are not contraindications to acupuncture therapy. Acupuncture needles are typically made of stainless steel, which does not contain latex.
Additionally, acupuncture does not involve the use of strawberries or any other substances that are common allergens. Therefore, latex and strawberry allergies do not pose a risk for acupuncture.
Correct Answer is D
Explanation
Choice A rationale:
Alopecia (hair loss) and diaphoresis (excessive sweating) can be side effects of certain medications, but they are not typically associated with allergic reactions.
Alopecia is often a delayed side effect of medications, meaning it can take weeks or months to develop after starting a medication. It is usually caused by the medication interfering with the normal hair growth cycle.
Diaphoresis can be a side effect of medications that affect the nervous system, such as antidepressants and anti-anxiety medications. It can also be a side effect of medications that cause fever, such as antibiotics.
Choice B rationale:
Heartburn and flatulence are common side effects of many medications, especially those that affect the digestive system.
Heartburn is a burning sensation in the chest that is caused by stomach acid refluxing back up into the esophagus. It is often triggered by eating certain foods, lying down after eating, or taking certain medications.
Flatulence is the release of gas from the intestines. It is often caused by eating foods that are difficult to digest, such as beans and cabbage. It can also be a side effect of medications that slow down the digestive system.
Choice C rationale:
Nausea and constipation are also common side effects of many medications.
Nausea is a feeling of sickness or unease in the stomach that can lead to vomiting. It is often caused by medications that irritate the stomach lining or that stimulate the vomiting center in the brain.
Constipation is a condition in which bowel movements are infrequent or difficult to pass. It is often caused by medications that slow down the movement of food through the intestines.
Choice D rationale:
Itchy rash and difficulty breathing are classic symptoms of an allergic reaction.
An allergic reaction occurs when the body's immune system overreacts to a substance that it perceives as a threat. This can cause a variety of symptoms, including itchy rash, difficulty breathing, swelling, hives, and anaphylaxis.
Itchy rash is a common symptom of allergic reactions to medications. It is often caused by the release of histamine, a chemical that is involved in the body's inflammatory response.
Difficulty breathing is a serious symptom of an allergic reaction that can be life-threatening. It is often caused by swelling of the airways, which can restrict airflow.
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