A nurse working in a hospital included abdominal assessment as part of patient assessment. In which patient would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes?

A patient who has gastroenteritis

A patient who has an early bowel obstruction

A patient who has paralytic ileus caused by abdominal surgery

A patient who has diarrhea

Answer and Explanation

The Correct Answer is C

Choice A reason: Gastroenteritis increases bowel motility due to inflammation and irritation, leading to hyperactive bowel sounds. Absent or decreased sounds are unlikely, as the gut remains active, often producing rushing or high-pitched sounds.

Choice B reason: Early bowel obstruction typically causes hyperactive, high-pitched bowel sounds due to increased peristalsis against the obstruction. Decreased or absent sounds may occur later in complete obstruction, but early stages are characterized by increased activity.

Choice C reason: Paralytic ileus, often post-abdominal surgery, halts peristalsis due to anesthesia, opioid use, or inflammation, resulting in decreased or absent bowel sounds. This reflects temporary gut paralysis, making it the expected finding after 5 minutes of auscultation.

Choice D reason: Diarrhea is associated with hyperactive bowel sounds due to rapid intestinal transit and fluid movement. The increased motility produces audible gurgling, making decreased or absent sounds unlikely in this condition.

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Correct Answer is A

Explanation

Choice A reason: An ascending colon ostomy produces very liquid stool because this proximal colon segment primarily absorbs water and electrolytes. Minimal water reabsorption occurs here, resulting in high fluid content in the stool, unlike more distal colon segments where stool becomes more formed.

Choice B reason: A descending colon ostomy produces semi-formed stool. This segment further absorbs water, concentrating fecal matter compared to the ascending colon. The stool is less liquid, reflecting increased water reabsorption, making it less characteristic of very liquid output.

Choice C reason: A sigmoid colon ostomy produces formed stool. The sigmoid colon stores and compacts feces, with significant water reabsorption, resulting in solid, less frequent output. This contrasts with the liquid stool expected from more proximal ostomies like the ascending colon.

Choice D reason: A transverse colon ostomy produces semi-liquid to semi-formed stool. Positioned between the ascending and descending colon, it absorbs more water than the ascending colon but less than the sigmoid, resulting in thicker output, not very liquid stool.

A. 1.5 tablets B. 2.5 tablets C. 2 tablets D. 1 tablet

Correct Answer is A

Explanation

Choice A reason: Furosemide 60 mg requires 1.5 tablets of 40 mg (60 ÷ 40 = 1.5). Scored tablets allow precise division, ensuring the correct dose. This calculation aligns with safe medication administration principles, delivering the prescribed amount accurately.

Choice B reason: Administering 2.5 tablets (100 mg) exceeds the prescribed 60 mg dose. Overdosing furosemide, a loop diuretic, risks excessive diuresis, leading to dehydration, hypokalemia, or hypotension, making this choice unsafe and incorrect.

Choice C reason: Two tablets (80 mg) also exceed the 60 mg order. This overdose could cause significant fluid and electrolyte imbalances, particularly in vulnerable patients, as furosemide promotes rapid sodium and water excretion, making this choice inappropriate.

Choice D reason: One tablet (40 mg) underdoses the patient, providing only 66.7% of the prescribed 60 mg. Inadequate dosing may fail to achieve therapeutic effects, such as edema reduction or blood pressure control, rendering this choice incorrect.

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A nurse working in a hospital included abdominal assessment as part of patient assessment. In which patient would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?

Correct Answer is A

Explanation

Physician order reads: Furosemide 60 mg po bid. Available: 40 mg scored tablets. What do you administer to the patient?

Correct Answer is A

Explanation

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