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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Institutionalism. B. Neglect. C. Emotional abuse. D. Stubborn behavior.

Correct Answer is B

Explanation

Neglect refers to the refusal or failure to provide an elderly person with necessary care, such as food, water, shelter, personal hygiene, medicine, and other essentials of daily living. Signs and symptoms of neglect in elders can include: dehydration, malnutrition, bed sores, fractures, urinary tract infections, contractures, over-medication, elopements, and poor personal hygiene. An elderly client who is admitted to the hospital looking unkempt, with dirty clothing, and smelling of urine may be suffering from neglect by a caregiver or by themselves (self-neglect).

Choice A is wrong because institutionalism is not a type of elder abuse but a term that describes the loss of individuality and autonomy that can occur in institutional settings such as nursing homes.

Choice C is wrong because emotional abuse is the infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct. Signs and symptoms of emotional abuse in elders can include: depression, confusion, withdrawal, isolation from friends and family. An elderly client who smells of urine may not necessarily be emotionally abused.

Choice D is wrong because stubborn behavior is not a type of elder abuse but a personality trait that may or may not be present in an elderly person.

Stubborn behavior does not indicate any harm or neglect inflicted upon an older adult by others or themselves.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 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?

Correct Answer is A

Explanation

An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine. The nurse is aware this may be:

Correct Answer is B

Explanation

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

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

An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

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?

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