A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

The patient may have paralytic ileus that could last 3-5 days

It is normal for all post-op patients not to have bowel sounds

The absence of bowel sounds is an abnormal finding

Document absent bowel sounds and notify the physician

Answer and Explanation

The Correct Answer is A

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

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Correct Answer is C

Explanation

Choice A rationale: Using enemas should not be the first response to constipation. There are various types of laxatives with different mechanisms of action that can be tried before resorting to enemas.
Choice B rationale: Habitual laxative use can contribute to chronic constipation, but it is not the most common cause. It is essential to identify and address the underlying cause of constipation.
Choice C rationale: If laxatives are not effective, trying a laxative with a different mechanism of action may be more successful in relieving constipation.
Choice D rationale: Chronic constipation should be assessed and addressed, as it can lead to complications and should not be dismissed as insignificant.

A. A client who is confined to bedrest. B. A client who has leg strength and can cooperate with the movement C. A client who has a thoracic incision. D. A client who has an abdominal incision.

Correct Answer is B

Explanation

Choice A rationale: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.

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A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Correct Answer is C

Explanation

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

Correct Answer is B

Explanation

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