Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action for the nurse to take?
Provide meticulous oral care and allow the patient to have ice chips for dry mouth.
Notify the surgeon immediately and prepare the patient for emergency surgery.
Keep the patient NPO and document the finding in the patient’s medical record.
Allow the patient to have clear liquids as tolerated to help bowel function return.
The Correct Answer is C
Choice A rationale:
While providing meticulous oral care and allowing ice chips for dry mouth can promote comfort, it does not address the primary concern of absent bowel sounds.
Ice chips could potentially stimulate bowel activity, but this is not a reliable or recommended method for managing absent bowel sounds in the immediate postoperative period.
It's essential to prioritize actions that assess and address the potential causes of absent bowel sounds, as they can indicate serious complications.
Choice B rationale:
Notifying the surgeon immediately and preparing for emergency surgery is not the appropriate first course of action in this situation.
Emergency surgery would be considered only if there were clear signs of a life-threatening complication, such as bowel perforation or peritonitis.
These complications would typically present with additional symptoms such as severe abdominal pain, fever, and hemodynamic instability.
Absent bowel sounds alone, without other concerning signs, do not warrant immediate surgical intervention.
Choice D rationale:
Allowing the patient to have clear liquids as tolerated is not appropriate when bowel sounds are absent. Introducing oral intake before bowel function has returned can increase the risk of nausea, vomiting, and aspiration.
It's crucial to wait for the return of bowel sounds before initiating oral intake to ensure proper digestion and minimize complications.
Choice C rationale:
Keeping the patient NPO (nothing by mouth) is the most appropriate action when bowel sounds are absent after major abdominal surgery.
This allows the bowel to rest and recover from the surgical manipulation.
It also prevents potential complications such as aspiration and nausea/vomiting that could arise from premature oral intake.
Documenting the absence of bowel sounds in the patient's medical record is essential for communication among healthcare providers and for monitoring the patient's progress.
This documentation provides a clear record of the patient's clinical status and facilitates appropriate decision-making regarding further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A lactose-free diet does not contraindicate acupuncture therapy. Lactose intolerance is a digestive condition that does not affect blood clotting or the ability to receive acupuncture safely.
Acupuncture needles are very fine and do not typically cause bleeding. Even if minor bleeding occurs, it is not a concern for individuals without bleeding disorders.
Therefore, a lactose-free diet does not pose a risk for acupuncture.
Choice B rationale:
Thrombocytopenia is a condition characterized by a low platelet count. Platelets are essential for blood clotting. Acupuncture involves the insertion of needles into the skin. This can cause minor bleeding, even when performed correctly.
In individuals with thrombocytopenia, even minor bleeding can be difficult to control and may lead to excessive bruising or hematoma formation.
Therefore, thrombocytopenia is a contraindication to acupuncture therapy due to the increased risk of bleeding complications.
Choice C rationale:
Herniated lumbar disks are a common condition that can cause back pain. Acupuncture is often used to treat back pain, including pain caused by herniated disks.
Studies have shown that acupuncture can be effective in reducing pain and improving function in patients with herniated disks.
Therefore, the presence of herniated lumbar disks does not contraindicate acupuncture therapy.
Choice D rationale:
Latex and strawberry allergies are not contraindications to acupuncture therapy. Acupuncture needles are typically made of stainless steel, which does not contain latex.
Additionally, acupuncture does not involve the use of strawberries or any other substances that are common allergens. Therefore, latex and strawberry allergies do not pose a risk for acupuncture.
Correct Answer is C
Explanation
Choice A rationale:
Inaccurate statement: While herbal supplements are derived from plant materials, this does not inherently guarantee their safety or non-toxicity. Some plants contain potent compounds that can have adverse effects, even in small doses.
Lack of regulation: Herbal supplements are not regulated by the FDA in the same way as prescription medications. This means that there is no guarantee of their purity, potency, or consistency.
Potential for interactions: Herbal supplements can interact with prescription medications, potentially leading to harmful side effects.
Choice B rationale:
Cost-related issue: The cost of herbal supplements can vary widely. While some may be less expensive than prescription medications, others can be quite costly.
Misleading focus: Emphasizing cost as a primary factor could lead patients to prioritize affordability over safety and effectiveness.
Choice C rationale:
Addresses quality concerns: This response directly addresses the lack of stringent quality standards for herbal supplements, highlighting a significant safety concern.
Encourages informed decision-making: This response encourages patients to carefully consider the potential risks and benefits of herbal supplements, prompting them to seek reliable information and discuss their choices with healthcare providers.
Choice D rationale:
Convenience vs. safety: While the convenience of herbal supplements may be appealing, this response does not address the potential safety concerns associated with their use.
Potential for misuse: Highlighting convenience could lead to patients using herbal supplements inappropriately or without necessary guidance from healthcare professionals.
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