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 D
Explanation
This aligns with the professional code of ethics for nurses, which states that nurses should respect the dignity, worth and rights of all human beings, regardless of the nature of their health problems or their social or legal status. The nurse should not let personal feelings or biases interfere with the quality of care or the ethical obligations of the profession.
Choice A is wrong because the nurse refuses to care of the client. This violates the principle of beneficence, which means doing good and preventing harm to others.
The nurse has a duty to provide care to all patients who need it, regardless of their personal opinions or feelings.
Choice B is wrong because the nurse delegates all care of the client to an assistant. This violates the principle of accountability, which means being answerable for one’s actions and decisions. The nurse cannot delegate tasks that require nursing judgment or assessment to an unlicensed person.
The nurse is responsible for ensuring that the patient receives safe and competent care.
Choice C is wrong because the nurse provides minimal care to keep the client alive. This violates the principle of non-maleficence, which means avoiding harm or injury to others.
The nurse should not provide substandard care or neglect the patient’s needs or preferences.
The nurse should strive to promote the health and well-being of the patient.
Correct Answer is D
Explanation
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.
Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.
It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.
Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.
It does not cause a rise in body temperature or muscle rigidity.
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