A nurse is preparing a care plan for a patient who is about to receive a transfusion of packed red blood cells. What should be the maximum duration for the total infusion time?

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

Choice A rationale
Nonfat milk is generally not a trigger for GERD101112131415. It is low in fat and thus less likely to relax the lower esophageal sphincter, which can lead to acid reflux1415.
Choice B rationale

Chocolate is known to trigger GERD symptoms1415. It contains caffeine and fat, which can relax the lower esophageal sphincter and cause acid reflux1415.
Choice C rationale
Oatmeal is generally not a trigger for GERD101112131415. It is a whole grain that is high in fiber, which can help control GERD symptoms1415.
Choice D rationale
Apples are generally not a trigger for GERD101112131415. They are non-citrus fruits and thus less likely to cause acid reflux1415.