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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Maintaining systolic BP between 136 and 140 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. Studies have shown that maintaining a lower systolic BP can help reduce the risk of recurrent stroke.
Choice B rationale
The client should aim to maintain systolic BP between 120 and 129 mm Hg. This range is associated with a reduced risk of recurrent stroke. Lifestyle modifications and antihypertensive therapy can help achieve this target.
Choice C rationale

Maintaining systolic BP between 141 and 145 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. This range is higher than the recommended target and may increase the risk of recurrent stroke.
Choice D rationale
Maintaining systolic BP between 130 and 135 mm Hg is not the recommended target for clients who have hypertension and have experienced a TIA789. The recommended target is lower to help reduce the risk of recurrent stroke.

A. To determine the pH of the gastric secretions. B. To supply nutrients via tube feedings. C. To administer medications. D. To decompress the stomach.

Correct Answer is D

Explanation

Choice A rationale
While a nasogastric tube can be used to determine the pH of gastric secretions, this is not typically the primary reason for its use in the treatment of pyloric obstruction.
Choice B rationale
While nasogastric tubes can be used to supply nutrients via tube feedings, this is not typically the primary reason for its use in the treatment of pyloric obstruction. In the case of pyloric obstruction, the focus is usually on relieving the obstruction rather than on feeding.
Choice C rationale
While nasogastric tubes can be used to administer medications, this is not typically the primary reason for its use in the treatment of pyloric obstruction.
Choice D rationale
The primary reason for the use of a nasogastric tube in the treatment of pyloric obstruction is to decompress the stomach. Pyloric obstruction can cause a buildup of gastric contents above the level of the obstruction, leading to symptoms such as nausea and vomiting. A nasogastric tube can be used to remove these contents and relieve symptoms.

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The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who has hypertension, which has resulted in a transient ischemic attack (TIA). What information regarding blood pressure (BP) management should the nurse discuss with the client?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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