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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

A. Stage 2 B. Stage 4 C. Stage 3 D. Stage 1

Correct Answer is A

Explanation

Choice A rationale:

Stage 2 pressure injuries are characterized by partial-thickness loss of skin layers involving the epidermis and/or dermis. They present as a red, blistered area, often with an intact or ruptured serum-filled blister. The wound bed is typically moist and may be painful. There is no exposure of underlying bone, tendon, or muscle.

Key features of Stage 2 pressure injuries that align with the patient's presentation:

Red, blistered area: This is a hallmark sign of Stage 2, indicating tissue damage and inflammation in the epidermis and dermis. Large size: The size of the wound suggests more extensive tissue damage, consistent with Stage 2 rather than Stage 1.

Absence of deeper tissue involvement: The absence of exposed bone, tendon, or muscle rules out Stage 3 or 4 pressure injuries.

Rationales for other choices:

Choice B: Stage 4

Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. This is not consistent with the patient's presentation, which does not describe exposed deeper tissues.

Choice C: Stage 3

Stage 3 pressure injuries involve full-thickness tissue loss, but without exposed bone, tendon, or muscle. They often present with a deep crater-like appearance and may have undermining or tunneling. The patient's wound does not exhibit these features, making Stage 3 less likely.

Choice D: Stage 1

Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. They do not involve blisters or open wounds. The patient's presentation clearly exceeds the features of Stage 1.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is scheduled to administer the patient’s next dose of vancomycin at 9:30 a.m. At what time should the nurse draw the patient’s blood to check the trough vancomycin level?

Correct Answer is B

Explanation

The patient has a large red, blistered area on the left hip.Which pressure injury stage will be recorded in the patient’s chart?

Correct Answer is A

Explanation

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection?

Which statement accurately describes patient tolerance to medications?

If a patient opts for an herbal supplement over a prescribed medication, what would be the nurse’s best response?

How should a nurse document the presence of thick, creamy yellow discharge on a patient’s dressing?

The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?

The nurse administers a medication to the patient.Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse? (Select all that apply.)

If a patient has a non-blanchable area of redness on the right malleolus, what stage of pressure injury should be recorded in the patient’s medical record?