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 A

Explanation

The correct answer is choice A. Cataracts are a cloudy, opaque area over the lens of one eye that can impair vision

Choice B is wrong because diabetic retinopathy is a condition that affects the blood vessels of the retina, not the lens. It can cause blurred vision, floaters, or vision loss

Choice C is wrong because glaucoma is a condition that damages the optic nerve due to high pressure in the eye. It can cause blind spots, halos around lights, or vision loss

Choice D is wrong because macular degeneration is a condition that damages the macula, the central part of the retina. It can cause blurred or no vision in the center of the visual field

: https://www.nhs.uk/conditions/cataracts/

: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and diseases/diabetic-retinopathy

: https://www.mayoclinic.org/diseases-conditions/glaucoma/symptoms causes/syc-20372839

: https://en.wikipedia.org/wiki/Macular_degeneration

A. Red, sore tongue. B. Pica. C. Splenomegaly and Jaundice. D. Paresthesias.

Correct Answer is C

Explanation

Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made.

Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown. Choice A is wrong because red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anemia.

Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia. Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia.

Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 gramsper deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.

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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 caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

Correct Answer is A

Explanation

Signs of hemolytic anaemias include:

Correct Answer is C

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)

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

A nurse is assisting with teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles?

A nurse is preparing to administer a medication to a client. Which of the following actions by the nurse demonstrates advocacy for client rights?

The nurse knows that the first-line treatment for localized inflammation (for example, on a patient’s ankle) is RICE. This acronym means:

A nurse is preparing an in-service presentation about preventing health care associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

Which of the following nursing diagnoses would typically NOT be associated with anemia?