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 C
Explanation
Choice A rationale:
Burning dried herbs is a form of traditional medicine, not allopathic medicine.
Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures.
It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being.
While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.
Choice B rationale:
Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine.
CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing.
It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain.
However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Choice C rationale:
Prescription of antibiotic medication is a hallmark of allopathic medicine.
Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease.
It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research.
Antibiotics are a type of medication that specifically targets and kills bacteria.
They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.
Choice D rationale:
Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine.
Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function.
While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Correct Answer is C
Explanation
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