Which assessment finding is the best Indicator to the nurse that a client's peristaltic activity (Gl motility) has resumed after surgery?
Client states they are hungry.
Presence of abdominal cramping.
Presence of bowel sounds.
Passing of flatus or stool
The Correct Answer is C
Bowel sounds are the result of muscular contractions in the intestines, indicating the movement of food, fluids, and gas through the gastrointestinal tract. After surgery, the normal function of the intestines, including peristalsis, may be temporarily impaired. As the intestines recover and regain their normal motility, bowel sounds will become audible.
The return of bowel sounds is an encouraging sign that the gastrointestinal system is starting to function again. It indicates that peristaltic activity has resumed and that the intestines are moving and processing the contents within. This is an essential step in the postoperative recovery process, as it indicates the return of normal gastrointestinal function and can lead to the resumption of oral intake and passage of stool.
While the other options may also be associated with the return of GI function, such as feeling hungry or passing flatus or stool, the presence of bowel sounds is a more reliable and direct assessment finding that indicates the resumption of peristaltic activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.
Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.
Correct Answer is A
Explanation
The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.
The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.
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