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 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.
Correct Answer is A
Explanation
Choice A rationale
Increasing daily protein intake is often recommended for clients with chronic pancreatitis. Protein is needed for healing and repairing tissues, and people with chronic pancreatitis may have increased protein needs.
Choice B rationale
Decreasing caloric intake when abdominal pain is present is not typically recommended for clients with chronic pancreatitis. Adequate nutrition, including sufficient calories, is important for managing this condition.
Choice C rationale
Increasing fat intake when experiencing loose stools is not typically recommended for clients with chronic pancreatitis. Fat can be difficult to digest for these clients and can contribute to loose stools.
Choice D rationale
Limiting alcohol intake to 2-3 drinks per week is not typically recommended for clients with chronic pancreatitis. Alcohol can exacerbate pancreatitis and should be avoided.
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