When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?

Withhold further opioid analgesics.

Obtain a prescription for a laxative.

Document the assessment finding.

Prepare to insert a nasogastric tube.

Answer and Explanation

The Correct Answer is C

Choice A reason: Withholding further opioid analgesics might be considered if the lack of bowel sounds is due to opioid-induced ileus. However, this is not the immediate action the nurse should take. The nurse should first document the finding and continue to assess the client's condition.

Choice B reason: Obtaining a prescription for a laxative might be appropriate if the client is experiencing constipation. However, administering a laxative without further assessment and documentation of the bowel sounds could lead to complications. The nurse should document the finding first and then collaborate with the healthcare provider for further interventions.

Choice C reason: Documenting the assessment finding is the most appropriate initial action. This ensures that the lack of bowel sounds is recorded in the client's medical record, which is crucial for ongoing monitoring and communication with the healthcare team. Proper documentation also helps in tracking changes in the client's condition and making informed decisions about subsequent care.

Choice D reason: Preparing to insert a nasogastric tube might be necessary if the client develops symptoms of bowel obstruction or other complications. However, this action should follow the documentation and further assessment of the client's condition. The nurse should document the finding first to provide a basis for any further interventions.

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Correct Answer is B

Explanation

Choice A reason: Leaving the door open so the client recognizes her belongings might help, but it is not the most effective solution. It relies on the client being able to remember and identify her possessions, which can be challenging with Alzheimer's disease.

Choice B reason: Placing a picture of the client on her door is an effective intervention. It provides a clear visual cue that the client can easily recognize, helping her to identify her own room without relying on memory alone. This approach uses a personal and familiar image, making it easier for the client to find her room.

Choice C reason: Putting a bright red balloon on the client's door may attract attention but does not provide a personal or meaningful cue for the client. While it might help distinguish the door, it lacks the personal connection needed for effective recognition.

Choice D reason: Enlarging the letters of her name on the door can help, but it still relies on the client's ability to read and recognize her name, which may be impaired. A picture of the client is a more straightforward and effective visual aid.

Correct Answer is ["0.4"]

Explanation

Step 1: Determine the concentration of enoxaparin. 60 mg is equivalent to 0.6 mall

Step 2: Set up the ratio to find how many mL corresponds to 40 mg. (40 mg) ÷ (60 mg) = x ÷ (0.6 mL)

Step 3: Solve for x. x = (40 mg) × (0.6 mL) ÷ (60 mg) x = 24 ÷ 60 x = 0.4 mL

So, the nurse should administer 0.4 mL

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When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is preparing a prescription for enoxaparin 40 mg subcutaneous (sub) daily. Enoxaparin is available in a pre-filled cartridge labelled, "60 mg per 0.6 mall" How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.4"]

Explanation

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