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 ["A","B","C","D"]

Explanation

Choice A rationale: The skin helps regulate body temperature by sweating and dilation or constriction of blood vessels.
Choice B rationale: The skin acts as a barrier, protecting the body from external threats such as pathogens and physical injury.
Choice C rationale: The skin is rich in sensory receptors, allowing for the perception of touch, pressure, pain, and temperature.
Choice D rationale: The skin plays a role in the production of vitamin D when exposed to sunlight.
Choice E rationale: Vitamin C production is not a function of the skin; vitamin C is obtained through diet.

A. Hemostasis B. Inflammatory phase C. Maturation phase D. Proliferation phase

Correct Answer is D

Explanation

Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.

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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

What are the functions of the skin? (Select All that Apply.)

Correct Answer is ["A","B","C","D"]

Explanation

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Correct Answer is D

Explanation

Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Ordered: Morphine sulfate 12 mg IM Available: Morphine sulfate 15 mg/mL How many mL will you administer?

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?