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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Auscultation of a bruit over the pedal pulse is not a typical symptom of DVT. A bruit is a sound heard over an artery due to turbulent blood flow. While it may indicate vascular disease, it is not a symptom of DVT121314.
Choice B rationale
Groin tenderness can be a symptom of DVT. DVT often causes pain or tenderness in the affected area, which can include the groin.
Choice C rationale

Pallor in the affected extremity is not a typical symptom of DVT. DVT can cause swelling and warmth in the affected area, but it does not typically cause pallor.
Choice D rationale
Cramping pain in one foot is not a typical symptom of DVT. DVT often causes pain or swelling in the affected leg, but the pain is not typically limited to the foot.

A. “Take pain relief medication such as acetaminophen to relieve discomfort associated with ascites.”. B. “Avoid high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners.”. C. “Ensure that you eat three large meals per day to keep your calories up.”. D. “Increase your activity as much as possible.

Correct Answer is B

Explanation

Choice A rationale
While acetaminophen can be used to relieve discomfort, it should be used with caution in patients with liver disease like cirrhosis, as it can potentially cause further liver damage.

Choice B rationale
Patients with cirrhosis, especially those with ascites, are often advised to limit their sodium intake. High-sodium foods can contribute to fluid retention and worsen ascites. Therefore, avoiding high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners is a key part of managing cirrhosis.
Choice C rationale
While maintaining adequate nutrition is important in cirrhosis, eating three large meals per day is not typically recommended. Instead, smaller, more frequent meals are often suggested.
Choice D rationale
While physical activity is generally beneficial, patients with cirrhosis and particularly those with complications such as ascites or encephalopathy may need to modify their activity levels based on their symptoms and overall health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 evaluating a client who is at risk for deep-vein thrombosis (DVT). Which of the following symptoms is an indication of DVT?

Correct Answer is B

Explanation

A nurse is preparing discharge instructions for a client who has cirrhosis of the liver. Which of the following statements should be included in the education materials?

Correct Answer is B

Explanation

A nurse admits a patient to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

What effect does chronic exposure to ultraviolet (UV) rays have on the skin that increases the risk for skin cancer?

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

A patient is scheduled for a liver biopsy. Which laboratory result would be of most concern to the nurse?

A nurse on a medical-surgical unit is caring for four patients who are 24 to 36 hours postoperative. Which of the following surgical procedures places the patient at risk for deep-vein thrombosis?