The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?
Document the bowel sounds as hypoactive
Administer prescribed drugs for constipation
Review dietary intake for the past 24 hours
Continue to listen for at least another 60 seconds
The Correct Answer is D
Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale
Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Fluid retention is not typically associated with hyperparathyroidism. Hyperparathyroidism is a condition in which the parathyroid glands produce too much parathyroid hormone, leading to high levels of calcium in the blood.
Choice B rationale
Impaired skin integrity is not typically associated with hyperparathyroidism.
Choice C rationale
Pathologic fractures are a potential complication of hyperparathyroidism. The condition can lead to osteoporosis due to loss of calcium from the bones, increasing the risk of fractures.
Choice D rationale
Dysphagia, or difficulty swallowing, is not typically associated with hyperparathyroidism.
Correct Answer is D
Explanation
Choice A rationale
Avoiding the use of tanning booths is an effective measure to prevent skin cancer as tanning booths emit harmful ultraviolet (UV) rays that can damage the skin and increase the risk of skin cancer.
Choice B rationale
Using sunscreen even on cloudy days is recommended as UV rays can penetrate through clouds and harm the skin.
Choice C rationale
Checking the skin monthly for any changes is a good practice as early detection of skin changes can lead to early diagnosis and treatment of skin cancer.
Choice D rationale
Eating a high fiber diet does not reduce the risk for developing skin cancer. While a healthy diet is important for overall health, it does not directly prevent skin cancer. Hypokalemia Explore
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