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
Potassium levels are not directly affected by lactulose. Lactulose is used to treat hepatic encephalopathy, a complication of cirrhosis, by reducing levels of ammonia in the blood.
Choice B rationale
Glucose levels are not directly affected by lactulose. Lactulose is used to treat hepatic encephalopathy, a complication of cirrhosis, by reducing levels of ammonia in the blood.
Choice C rationale
Bicarbonate levels are not directly affected by lactulose. Lactulose is used to treat hepatic encephalopathy, a complication of cirrhosis, by reducing levels of ammonia in the blood.
Choice D rationale
In clients who have cirrhosis, lactulose is used to decrease levels of ammonia in the bloodstream. Lactulose works by changing the acidity of the gut, which helps trap ammonia in the colon and prevent it from being absorbed into the bloodstream.

A. Blood pressure 102/66 mm Hg B. Yellow-green drainage on the surgical incision C. Respiratory rate 18/min D. Straw-colored urine from an indwelling urinary catheter

Correct Answer is B

Explanation

Choice A rationale

A blood pressure of 102/66 mm Hg is within the normal range and would not typically need to be reported to the provider.
Choice B rationale
Yellow-green drainage on the surgical incision could be a sign of a wound infection. Infections after surgery can lead to serious complications and should be reported to the provider immediately.
Choice C rationale
A respiratory rate of 18/min is within the normal range and would not typically need to be reported to the provider.
Choice D rationale
Straw-colored urine from an indwelling urinary catheter is normal and would not typically need to be reported to the provider.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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