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 C

Explanation

Choice A rationale
Telling the patient that their liver has been destroyed by alcohol might not be the most effective way to motivate change. It could potentially lead to feelings of hopelessness and deter the patient from seeking help.
Choice B rationale

Introducing the patient to other people might not directly motivate them to change their alcohol consumption habits. However, it could potentially provide them with a supportive network that could help them in their journey to sobriety.
Choice C rationale
Educating the patient about the disease can be very beneficial. Understanding the effects of alcohol on their liver and the potential consequences of continued drinking can motivate them to change.
Choice D rationale
Instructing the patient to cut back to drinking one drink per day might not be the best advice for a patient with cirrhosis of the liver. Complete abstinence from alcohol is usually recommended for these patients to prevent further liver damage.

A. Situation. B. Recommendation. C. Assessment. D. Background.

Correct Answer is D

Explanation

Choice A rationale
The situation component of the SBAR tool typically involves a brief description of the current problem or concern. Stating that a bowel resection was performed does not describe a current problem or concern.
Choice B rationale
The recommendation component of the SBAR tool involves suggesting a course of action or asking for assistance. Stating that a bowel resection was performed does not suggest a course of action or ask for assistance.
Choice C rationale
The assessment component of the SBAR tool involves sharing your analysis or opinion about the situation. Stating that a bowel resection was performed does not share an analysis or opinion.
Choice D rationale
This is the correct answer. The background component of the SBAR tool involves providing context or background information relevant to the situation. Stating that a bowel resection was

performed provides relevant background information about the patient’s recent medical history. DysphagiaDysphagia Explore

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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 patient who has cirrhosis of the liver and is having difficulty eliminating alcohol consumption because many of their friends drink alcohol socially. Which of the following steps should the nurse include to motivate the patient to change?

Correct Answer is C

Explanation

A nurse is transferring a patient to the surgical unit postoperatively. During the handoff report, the nurse states that “Dr. Jones performed a bowel resection.”. Which section of the SBAR Communication tool does this statement address?

Correct Answer is D

Explanation

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