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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The role of the risk manager is to identify and analyze the factors that contributed to the adverse event and to implement strategies to prevent or reduce the likelihood of recurrence. The risk manager is not concerned with assigning blame or protecting the staff from litigation, but rather with improving the quality and safety of care.
Choice A is wrong because it implies a punitive approach that does not address the underlying system issues.
Choice B is wrong because it suggests a defensive attitude that does not foster a culture of learning and improvement.
Choice D is wrong because it assumes that the nurses were not aware of the patient’s fall risk, which may not be the case.
The risk manager should investigate all aspects of the situation, including the communication and documentation of the patient’s fall risk assessment and interventions.
Correct Answer is C
Explanation
This is a responsibility of the nurse in the process of informed consent, which is the patient’s choice to have a treatment or procedure based on their full understanding of its benefits, risks, and alternatives. The nurse should provide written materials in the client’s spoken language, when possible, and verify that the client comprehends and consents to the care and procedures.
Choice A is wrong because confirming that the client is competent to sign for the procedure is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only obtain consent when initiating care or reviewing consent before providing care ordered by another health professional.
Choice B is wrong because discussing the risks of the procedure with the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.
Choice D is wrong because explaining alternatives to the procedure to the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.
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