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 B
Explanation
The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.
Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.
Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.
Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.
Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.
Correct Answer is A
Explanation
Nonmaleficence is the ethical principle of doing no harm or preventing harm to a client. It is based on the Hippocratic oath of “primum non nocere” or “first, do no harm”. It means that the nurse should act in the best interest of the client and avoid any actions that could cause injury or suffering.
Choice B. Fidelity is the ethical principle of being faithful and loyal to a client.
It means that the nurse should keep promises, respect confidentiality, and maintain trust.
Choice C. Justice is the ethical principle of treating clients fairly and equally.
It means that the nurse should distribute resources and services based on the client’s needs and not on personal biases.
Choice D. Autonomy is the ethical principle of respecting a client’s right to make their own decisions.
It means that the nurse should inform the client of their options and support their choices, as long as they do not harm others.
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