The nurse cares for a client who has just returned from abdominal surgery. The nurse has completed the focused GI assessment and does not hear any bowel sounds when auscultating the client's abdomen. What is the nurse's best action?
Palpate the abdomen.
Prepare to insert a NG tube.
Document the findings.
Percuss the abdomen.
The Correct Answer is C
A. Palpation should be done after auscultation and is not the best next action when no bowel sounds are heard postoperatively.
B. An NG tube is not routinely inserted based solely on the absence of bowel sounds; further assessment and provider orders are required.
C. Absent or diminished bowel sounds are expected immediately after abdominal surgery due to temporary ileus. The nurse should document the findings and continue monitoring.
D. Percussion may follow auscultation, but it does not replace the need to document absent bowel sounds as a post-op finding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Carbohydrates are not appropriate at this stage; the client is hyperglycemic and requires glucose-lowering interventions, not additional carbohydrates.
B. Dietary instruction is important for long-term management but is not a priority during the acute phase of HHS, which is a medical emergency.
C. Fluid replacement is the priority. Clients with HHS experience extreme dehydration due to osmotic diuresis. Rapid IV fluid administration is essential to restore perfusion, correct hypotension, and prevent shock.
D. Oxygen may be used if the client has respiratory distress, but it is not the primary intervention in HHS, where dehydration is the most urgent concern.
Correct Answer is A
Explanation
A. A biopsy involves obtaining a tissue sample for microscopic examination, which is the gold standard for confirming the presence and type of cancer.
B. While a biopsy may incidentally detect infection, it is not primarily used to differentiate infection from cancer.
C. While biopsies can identify cancer in a specific tissue, imaging studies and additional biopsies are typically needed to confirm metastasis.
D. Although molecular testing on biopsy samples can be done later to detect mutations, the primary purpose of a biopsy is to diagnose whether cancer is present.
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