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 D

Explanation

This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.

Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.

Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.

Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.

A. Maintain a regular sleep routine. B. Eat 3 large meals a day. C. Limit refined sugar, fried foods, and processed foods. D. Take daily walks. E. Take more coffee.

Correct Answer is ["A","C","D"]

Explanation

Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.

Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy. Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body.

These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.

Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system.

Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue.

Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms

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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

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

Correct Answer is D

Explanation

A nurse is caring for a patient who has complaints of fatigue. If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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