A nurse is assessing a client who is 3 days postoperative from abdominal surgery. The client reports nausea but has not had a bowel movement since surgery. The nurse notes hypoactive bowel sounds in all quadrants and mild abdominal distention. Which nursing intervention should the nurse implement first to promote gastrointestinal motility?
Apply firm abdominal palpation to assess for tenderness and stimulate bowel sounds.
Notify the provider immediately to prepare for nasogastric tube insertion due to absence of bowel sounds.
Encourage the client to begin ambulation as tolerated to stimulate peristalsis.
Administer a prescribed stimulant laxative to induce bowel movements.
The Correct Answer is C
Choice A reason: Firm abdominal palpation is contraindicated in a client with suspected postoperative ileus and distention, as it can exacerbate patient discomfort, increase vagal response, and potentially injure surgical sites. Palpation does not reliably stimulate peristalsis and is not a therapeutic intervention for promoting gastrointestinal motility.
Choice B reason: Nasogastric tube insertion is a therapeutic intervention reserved for severe, persistent ileus or mechanical obstruction characterized by intractable vomiting and significant abdominal distention. It is not the initial intervention for a client who is 3 days postoperative and presenting with mild symptoms, as early mobilization is the preferred first-line management.
Choice C reason: Early and frequent ambulation is the gold-standard nursing intervention for promoting the return of gastrointestinal function postoperatively. Physical activity increases core muscle engagement, improves lymphatic drainage, and provides mechanical stimulation to the bowel, which helps overcome the inhibitory effects of anesthesia and surgical trauma on peristalsis.
Choice D reason: While laxatives may eventually be ordered, the administration of stimulant laxatives in a patient with a suspected ileus can cause intense, painful intestinal contractions against a sluggish bowel, potentially leading to further distress. Non-pharmacological measures like ambulation are prioritized before pharmacological stimulation in the management of postoperative ileus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The endocardium is the innermost layer of the heart, consisting of endothelial cells that line the chambers and valves. While it provides a smooth, frictionless surface for blood flow, it does not possess the contractile properties necessary to generate the mechanical force required for pumping blood.
Choice B reason: The myocardium is the thick, muscular middle layer of the heart wall. It is composed of specialized cardiac muscle cells that possess the contractile ability to generate high pressure and force, making it the primary engine responsible for the mechanical pumping action that circulates blood throughout the body.
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Choice C reason: The epicardium is the outer serous layer of the heart wall, also known as the visceral layer of the serous pericardium. It serves a protective function and contains coronary blood vessels and adipose tissue, but it plays no role in the direct contractile force production for blood circulation.
Choice D reason: The pericardium is the fibrous sac that surrounds and protects the heart. It provides physical support and prevents the heart from over-expanding. While it is essential for cardiac health, it is a structural covering and does not contribute to the contractile muscular force of the heart chambers.
Correct Answer is B
Explanation
Choice A reason: Morning stiffness that resolves after a short period of activity is a hallmark sign of inflammatory arthritic conditions such as rheumatoid arthritis or osteoarthritis. It is a well-documented and anticipated symptom of the disease process and does not typically represent an acute, unexpected complication.
Choice B reason: Deviation of knee alignment, especially when accompanied by new-onset erythema and localized heat, is highly suggestive of an acute inflammatory process, such as septic arthritis or a significant structural failure. This requires immediate clinical evaluation to rule out infection, crystal-induced arthropathy, or catastrophic mechanical joint instability.
Choice C reason: Crepitus is the audible or palpable grating sensation caused by the friction of damaged articular cartilage rubbing against bone. It is a common finding in progressive degenerative joint disease and is generally considered an expected, though symptomatic, progression of chronic osteoarthritis rather than an unexpected emergency.
Choice D reason: Pain that is exacerbated by weight-bearing and activity and subsequently relieved by rest is the classic clinical presentation of mechanical joint disease, such as osteoarthritis. This pain pattern is the expected clinical manifestation of the underlying structural pathology and does not indicate a new, unexpected complication.
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