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 D

Explanation

Choice A reason: Lethargy and lack of appetite are symptoms that might indicate hypothyroidism or an insufficient dosage of levothyroxine. These symptoms are not typically associated with a dosage that is too high.

Choice B reason: Bradycardia and constipation are also indicative of hypothyroidism or an inadequate dosage of levothyroxine. These symptoms suggest a need for a higher dosage rather than indicating that the current dosage is too high.

Choice C reason: Muscle cramping and dry, flushed skin can be associated with electrolyte imbalances or dehydration, but they are not specific symptoms of an excessive dosage of levothyroxine.

Choice D reason: Palpitations and shortness of breath are signs of hyperthyroidism, which can occur if the dosage of levothyroxine is too high. These symptoms indicate that the client's metabolism is excessively stimulated, leading to cardiovascular strain and respiratory distress. It is crucial for the nurse to monitor these symptoms and adjust the medication dosage accordingly.

A. "I will lift weights every other day." B. "I will avoid sitting and crossing my legs." C. "I will be able to stand as long as my legs do not hurt." D. "I will need to get someone to walk my dog."

Correct Answer is B

Explanation

Choice A reason: Lifting weights every other day might not be harmful, but it is not specifically relevant to managing chronic venous insufficiency. The statement does not indicate an understanding of the specific care needed for this condition.

Choice B reason: Avoiding sitting and crossing the legs is an important measure to prevent worsening of chronic venous insufficiency. Crossing legs can impede blood flow and worsen symptoms. This statement reflects an understanding of how to manage the condition.

Choice C reason: Standing for prolonged periods, even if there is no pain, can exacerbate venous insufficiency. This statement shows a misunderstanding of the importance of movement and elevation of the legs to promote blood flow.

Choice D reason: Walking is generally encouraged to promote circulation in clients with venous insufficiency. The statement about needing someone else to walk the dog may indicate a misunderstanding of the benefits of regular, gentle exercise.

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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

A 26-year-old client is admitted to the hospital for treatment of a simple goitre, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

Correct Answer is D

Explanation

A client with chronic venous insufficiency is being discharged from the hospital and plans to return home. Which client statement indicates an understanding of home care instructions?

Correct Answer is B

Explanation

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