The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

Document the bowel sounds as hypoactive

Administer prescribed drugs for constipation

Review dietary intake for the past 24 hours

Continue to listen for at least another 60 seconds

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

Choice A rationale
While assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale

Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.

A. Administer IV 0.9% sodium chloride injection (normal saline) B. Administer IV push (IVP) of diazepam C. Administer IV push (IVP) of gabapentin D. Administer IV 0.9% sodium chloride and 5% glucose (dextrose)

Correct Answer is D

Explanation

For a patient with hypoglycemia who has experienced a suspected seizure, the immediate intervention would be to administer IV 0.9% sodium chloride and 5% glucose (dextrose). This helps to quickly raise the patient’s blood glucose levels and manage the seizure.

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The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Correct Answer is D

Explanation

For the patient with hypoglycemia who has experienced a suspected seizure, which intervention would the nurse implement immediately?

Correct Answer is D

Explanation

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