The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Encouraging the client to increase intake of foods that contain high fat to increase GI motility.

Encouraging the client to increase solid food intake to promote peristalsis.

Encouraging the client to increase intake of foods that contain fiber.

Withholding food and oral fluids until intestinal mobility has returned.

Answer and Explanation

The Correct Answer is D

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

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Correct Answer is C

Explanation

This is because the cognitive domain of learning involves knowledge and understanding of information. By stating 3 ways to avoid his triggers, the patient demonstrates that he has learned and comprehended the information about prevention of inflammation.

Choice A is wrong because it belongs to the psychomotor domain of learning, which reflects learning behavior achieved through neuromuscular motor activities. Checking blood sugar is a physical skill, not a cognitive one.

Choice B is wrong because it belongs to the affective domain of learning, which characterizes the emotional arena reflected by learners’ beliefs, values and interests.

Discussing feelings about dietary changes is an affective outcome, not a cognitive one.

Choice D is wrong because it also belongs to the psychomotor domain of learning, as it involves demonstrating proper use of inhaler, which is another physical skill.

A. Hypothermia. B. Normothermia. C. Hyperthermia. D. Malignant hyperthermia.

Correct Answer is A

Explanation

Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased

shiver reflex, and lower immunity. They also tend to have a lower body temperature and may not develop fevers when they contract a viral or bacterial illness.

Choice B. Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).

Choice C. Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F).

Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.

Choice D. Malignant hyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants.

It is not related to thermoregulation in elderly people.

Question 5.

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The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

Correct Answer is C

Explanation

Which thermoregulatory condition is an elderly person most at risk for?

Correct Answer is A

Explanation

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