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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis can be evaluated by observing the patient’s stool. Pancreatic enzyme replacement therapy (PERT) is used to improve digestion and absorption of nutrients in patients with pancreatic insufficiency, a common complication of chronic pancreatitis. One of the primary goals of PERT is to reduce steatorrhea, or fatty stools, which is a common symptom of pancreatic insufficiency. Therefore, observing changes in the patient’s stool, such as a reduction in fat content, can help evaluate the effectiveness of PERT567.
Choice B rationale
While saliva plays a role in the initial stages of digestion, it is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in saliva are not indicative of the effectiveness of this therapy.
Choice C rationale
Nasal mucus is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in nasal mucus are not indicative of the effectiveness of this therapy.
Choice D rationale
Urine is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in urine are not indicative of the effectiveness of this therapy.
Correct Answer is B
Explanation
Choice A rationale
While Vitamin B is important for overall health, it is not specifically known to promote wound healing.
Choice B rationale
Protein is essential for wound healing. It helps to repair body tissues and is vital for skin repair and immunity. Inadequate protein intake can impair collagen formation and slow down the wound healing process.
Choice C rationale
While calcium is important for bone health, it is not specifically known to promote wound healing.
Choice D rationale
Vitamin D helps the body absorb calcium, but it is not specifically known to promote wound healing.
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