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: Frequency of sexual activity can provide useful information about the client's sexual health and habits, but it is not the most critical information needed to address erectile dysfunction. The nurse needs to determine if there are any immediate factors contributing to ED, such as medication side effects.

Choice B reason: Environmental toxin exposure can have long-term health effects, including on sexual function. However, it is not the most urgent factor to consider when evaluating a client with erectile dysfunction. Immediate information about medications and medical history is more pertinent.

Choice C reason: Familial history of diabetes is important because diabetes can affect erectile function due to vascular and neurological complications. Yet, while this background information is useful, it is not the most immediate concern compared to potential medication side effects.

Choice D reason: The current medication regimen is the most important information for the nurse to obtain. Many medications can contribute to erectile dysfunction as a side effect. By identifying the medications the client is taking, the nurse can determine if ED might be a side effect and discuss possible adjustments or alternatives with the healthcare provider.

A. Effectively manage pain, discomfort, and diarrhea. B. Ensure careful fluid and electrolyte balance. C. Reduce number and severity of acute exacerbations. D. Maintain a diet that is high in fibber content.

Correct Answer is C

Explanation

Choice A reason: Effectively managing pain, discomfort, and diarrhea is crucial for the client's immediate comfort and quality of life. However, it does not address the underlying goal of preventing disease progression.

Choice B reason: Ensuring careful fluid and electrolyte balance is essential, especially during acute exacerbations. However, this is more of an immediate concern rather than a long-term goal.

Choice C reason: Reducing the number and severity of acute exacerbations is the most important long-term goal. Achieving this will help maintain remission, prevent complications, and improve the overall prognosis for the client.

Choice D reason: Maintaining a diet that is high in fibber content can be beneficial for overall health but may not always be suitable for clients with ulcerative colitis, especially during flare-ups. This is not the primary long-term goal for managing the condition.

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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 male client comes to the clinic with concerns of erectile dysfunction (ED). Which information is most important for the nurse to obtain?

Correct Answer is D

Explanation

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

Correct Answer is C

Explanation

During a home visit, the nurse should evaluate the effectiveness of a client's treatment for chronic obstructive pulmonary disease (COPD) by assessing for which primary symptom?

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The nurse is planning discharge teaching for a client who has cystitis. Which information should the nurse include in the teaching plan?

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