The nurse is caring for a client who is one day post op after having abdominal surgery. While auscultating bowel sounds for a full one minute, the nurse hears 3 bowel sounds. The nurse would chart this as bowel sounds.

hyperactive

active

hypoactive

absent

Answer and Explanation

The Correct Answer is C

In a postoperative client one day after abdominal surgery, hearing only 3 bowel sounds in one minute indicates hypoactive bowel sounds. Normal bowel sounds are typically described as "active" and occur at a rate of 5 to 30 per minute. Hypoactive bowel sounds are decreased in frequency, often occurring less than 5 per minute, and may indicate decreased gastrointestinal motility, which is common after abdominal surgery due to factors such as anesthesia, pain medication, and bowel manipulation during surgery.

A. Hyperactive: Hyperactive bowel sounds, also known as "borborygmi," are increased in frequency and intensity. They are often loud, gurgling sounds and may indicate increased gastrointestinal motility or the presence of diarrhea. This description does not fit the scenario described.

B. Active: While "active" bowel sounds are within the normal range, hearing only 3 bowel sounds in one minute suggests decreased frequency, indicating hypoactivity rather than normal activity.

C. Hypoactive: Hypoactive bowel sounds are decreased in frequency, occurring less than 5 per minute. This finding is commonly observed in postoperative clients due to factors such as anesthesia and opioid pain medication.

D. Absent: Absent bowel sounds are concerning and may indicate ileus or bowel obstruction. In this scenario, hearing 3 bowel sounds indicates some bowel motility, ruling out the classification of absent bowel sounds.

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Correct Answer is C

Explanation

A. frequent enuresis: Frequent enuresis refers to the involuntary loss of urine during the day or night, often associated with bedwetting. It does not specifically describe the sudden, compelling need to urinate described by the client.

B. urinary frequency: Urinary frequency is the need to urinate more often than usual, which may or may not be associated with urgency. It does not fully capture the sudden, urgent need to urinate described by the client.

C. urinary urgency: Urinary urgency is the sudden, compelling need to urinate that cannot be delayed. This aligns with the client's description of feeling like they have to go immediately and cannot wait. Therefore, this is the most appropriate choice.

D. urge incontinence: Urge incontinence involves the involuntary loss of urine associated with a sudden, strong desire to urinate. While similar to urinary urgency, it specifically refers to the leakage of urine that can occur due to the inability to reach the toilet in time after feeling the urge to urinate. However, the client's statement does not indicate actual urine leakage, making this option less appropriate than urinary urgency.

A. Baked chicken, canned peas & carrots, macaroni & cheese, and hot tea B. Pepperoni pizza, salad, and a diet soda C. Baked turkey breast, corn on the cob, dinner roll, and skim milk D. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea

Correct Answer is C

Explanation

A. Baked chicken, canned peas & carrots, macaroni & cheese, and hot tea: This meal option contains canned vegetables, which are likely to be high in sodium due to added salt for preservation. Additionally, macaroni and cheese are typically high in sodium, and hot tea may contain added sodium if processed or prepared with salt. Therefore, this option is not suitable for a client on a low-sodium diet.

B. Pepperoni pizza, salad, and a diet soda: Pepperoni pizza is a high-sodium food due to the processed meats and cheese. Salad can be a healthy option, but it depends on the dressing and toppings; if these are high in sodium, it may not be appropriate. Diet soda typically does not contain sodium, but it is not an ideal beverage choice for a client with fluid volume excess. Overall, this option is not suitable for a low-sodium diet.

C. Baked turkey breast, corn on the cob, dinner roll, and skim milk: This is the correct answer. Baked turkey breast is a lean protein source that is naturally low in sodium. Corn on the cob and skim milk are also low in sodium. A dinner roll may contain some sodium, but if chosen wisely, it can be a suitable option for a low-sodium diet. Overall, this meal option provides a balanced and low-sodium meal for a client with fluid volume excess.

D. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea: Bologna, potato chips, and iced tea are all high-sodium food items and not suitable for a client on a low-sodium diet. While sliced cucumbers are low in sodium, they alone cannot offset the high sodium content of the other items in this meal option.

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The nurse is caring for a client who is one day post op after having abdominal surgery. While auscultating bowel sounds for a full one minute, the nurse hears 3 bowel sounds. The nurse would chart this as bowel sounds.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client tells the nurse. "The need to urinate comes on me all of a sudden, and it feels as though I have to go immediately-that I can't wait." The nurse charts that the client is experiencing:

Correct Answer is C

Explanation

What meal option should a nurse choose for a client with fluid volume excess who has been placed on a low-sodium diet?

Correct Answer is C

Explanation

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