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 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.

A. Patient will exhibit O2 saturation > 92% by discharge. B. Teach pursed-lip breathing prior to discharge. C. Patient will state 2 ways to decrease chance of reinfection by the end of shift. D. Patient will demonstrate pursed-lip breathing.

Correct Answer is C

Explanation

This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.

Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.

The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.

Choice B is wrong because it is not a goal statement, but an intervention.

A goal statement should describe the expected outcome of the intervention, not the intervention itself.

Choice D is wrong because it is not measurable or time-bound.

A goal statement should have a clear indicator of how and when the outcome will be achieved.

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 client is hospitalized and is in police custody after being arrested for driving while intoxicated for the third time. The nurse assigned to the client lost her brother to a drunk driver two years prior. Which action on the part of the nurse aligns with the professional code of ethics for nurses?

Correct Answer is D

Explanation

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

Correct Answer is C

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?

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

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?

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

A client’s bloodwork indicates that he has severe hypokalemia. What is a priority nursing intervention?

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel?