A patient had abdominal surgery 2 hours ago. She is stating that she is hungry and would like something to eat. What is the first consideration that the nurse must make before allowing the patient to eat?

Urinary status

Skin turgor

Pain level

Bowel sounds

Answer and Explanation

The Correct Answer is D

Choice A reason: Urinary status, such as output, monitors hydration and kidney function post-surgery but is unrelated to safe oral intake. Abdominal surgery risks paralytic ileus, where intestinal motility ceases, increasing aspiration risk if food is consumed. Bowel sounds indicate gastrointestinal function recovery, making urinary status a secondary consideration for dietary decisions.

Choice B reason: Skin turgor assesses hydration but does not determine readiness for oral intake post-surgery. Abdominal surgery can impair peristalsis, causing ileus, which risks vomiting or obstruction if food is introduced prematurely. Assessing bowel sounds confirms intestinal motility, critical for safe eating, while skin turgor is irrelevant to gastrointestinal recovery.

Choice C reason: Pain level is important for patient comfort but not the primary consideration for eating post-surgery. Pain may indicate complications, but absent bowel sounds suggest ileus, a condition where the gut lacks motility, risking aspiration. Bowel sounds confirm peristalsis, ensuring safe digestion, making pain a secondary factor in this context.

Choice D reason: Bowel sounds indicate gastrointestinal motility, critical after abdominal surgery to prevent complications like ileus. Absent sounds suggest impaired peristalsis, increasing risks of vomiting or obstruction if food is consumed. Auscultating active bowel sounds confirms the gut’s readiness to process food, making this the primary consideration before allowing eating to ensure safety.

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Correct Answer is C

Explanation

Choice A reason: Stating the feeding order (cereal, then eggs) dismisses the client’s autonomy, reducing dignity. Offering choice empowers the client, respecting their preferences. This approach lacks patient-centered care, potentially making the client feel controlled, per dignity and psychosocial care principles.

Choice B reason: Assuming the client dislikes being fed is judgmental and undermines dignity, implying resistance. This statement dismisses the client’s feelings, reducing autonomy and respect. A dignified approach involves choice and collaboration, not confrontation, per patient-centered care and ethical nursing standards.

Choice C reason: Asking what part of the meal the client wants first promotes dignity by offering choice and autonomy. It respects the client’s preferences, fostering a sense of control and respect during a dependent task, aligning with patient-centered care and dignity principles in nursing.

Choice D reason: Expressing a wish for more time suggests inadequacy, potentially diminishing the client’s sense of value. This focuses on the nurse’s limitations, not the client’s dignity. Offering choices enhances respect, whereas this statement risks disempowerment, per psychosocial care and dignity standards.

A. Hemoglobin (Hgb) 11.3 g/dL B. Creatinine 1.9 mg/dL C. Hematocrit (Hct) 56% D. Serum albumin 2.8 g/dL

Correct Answer is D

Explanation

Choice A reason: Hemoglobin of 11.3 g/dL is low but not specific to malnutrition, as it may indicate anemia from various causes, like iron deficiency or chronic disease. Malnutrition affects protein levels more directly. This value requires further investigation but does not confirm malnutrition, as it reflects red blood cell status, per hematological assessment.

Choice B reason: Creatinine of 1.9 mg/dL suggests renal impairment, as it exceeds normal ranges (0.6-1.2 mg/dL), reflecting reduced kidney filtration. Malnutrition typically lowers creatinine due to muscle wasting, not elevates it. This value indicates kidney dysfunction, not nutritional status, making it irrelevant to malnutrition assessment, per renal physiology.

Choice C reason: Hematocrit of 56% indicates hemoconcentration, often from dehydration, not malnutrition. Malnutrition may cause anemia, lowering hematocrit. Elevated hematocrit reflects increased red blood cell proportion, unrelated to protein-energy deficits. This finding does not align with malnutrition’s impact on nutritional biomarkers, per laboratory diagnostic standards.

Choice D reason: Serum albumin of 2.8 g/dL (normal 3.5-5.0 g/dL) indicates malnutrition, as low levels reflect reduced protein synthesis due to inadequate dietary intake. Albumin is a sensitive marker of chronic nutritional status, decreasing in protein-energy malnutrition. This finding directly correlates with malnutrition’s physiological impact, per nutritional assessment guidelines.

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A patient had abdominal surgery 2 hours ago. She is stating that she is hungry and would like something to eat. What is the first consideration that the nurse must make before allowing the patient to eat?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is feeding a client. Which statement would help a person maintain dignity while being fed?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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