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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Documentation of care during the procedure is typically the responsibility of the circulating nurse, not the scrub nurse/tech.
B. Updating the family is also the role of the circulating nurse or the surgical liaison.
C. The scrub nurse or technician is responsible for maintaining the sterile field, preparing instruments, and passing instruments to the surgeon during the operation.
D. Verifying consent is a preoperative responsibility and typically handled by the circulating nurse or provider, not the scrub tech/nurse.
Correct Answer is B
Explanation
A. This is incorrect
B. Each dose is 80 mg, and each tablet is 20 mg
80 mg ÷ 20 mg = 4 tablets per dose
4 tablets/dose × 2 doses/day = 8 tablets per day
Answer: B. 8 tabs
C. This is incorrect
D. This is incorrect
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