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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The right ventricle receives deoxygenated blood from the right atrium through the tricuspid valve. It is responsible for pumping this deoxygenated blood into the pulmonary circulation via the pulmonary artery to be oxygenated in the lungs, not for receiving oxygenated blood from the veins.
Choice B reason: The right atrium receives deoxygenated systemic venous blood returning from the body via the superior and inferior vena cava. It serves as the initial collection chamber for the right side of the heart, which is dedicated to the pulmonary circulation circuit, not the systemic oxygenated circuit.
Choice C reason: The left ventricle receives oxygenated blood from the left atrium through the mitral valve. It is the thick-walled muscular chamber responsible for pumping this oxygenated blood out through the aorta to the rest of the systemic circulation to meet the body's metabolic demands.
Choice D reason: The left atrium is the receiving chamber for the four pulmonary veins, which carry oxygen-rich blood back to the heart from the lungs. This chamber holds the oxygenated blood before it passes through the mitral valve into the left ventricle for systemic distribution.
Correct Answer is D
Explanation
Choice A reason: Pain during range of motion exercises following prolonged rest is a frequent finding associated with chronic degenerative conditions like osteoarthritis or disuse atrophy. While clinically significant, it is a common expected symptom rather than an indicator of a new, acute, or unexpected severe neurological or muscular complication.
Choice B reason: Slightly reduced range of motion accompanied by symmetric weakness is a finding often seen in chronic atrophy or generalized musculoskeletal decline. While it requires ongoing monitoring, it is generally consistent with the expected progression of chronic disuse or systemic weakness rather than an acute unexpected pathological event.
Choice C reason: Full range of motion with gravity eliminated represents a specific muscle strength grade (Grade 2). In a patient with established muscle atrophy, this finding is expected as it demonstrates some level of functional muscular capacity without indicating a new, acute, or unexpected severe decline in motor integrity.
Choice D reason: A Grade 0 strength indicates complete paralysis with no palpable or visible muscle contraction. If a patient presenting for a routine assessment suddenly demonstrates unilateral Grade 0 strength, it signifies an acute, unexpected, and potentially severe neurological or vascular compromise, such as a stroke, spinal injury, or nerve root compression.
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