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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Peptic ulcer disease is not a common complication of difficulty swallowing after a stroke. It is typically caused by an infection with the bacterium Helicobacter pylori or long-term use of nonsteroidal anti-inflammatory drugs.
Choice B rationale
Dumping syndrome is not a common complication of difficulty swallowing after a stroke. It is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight.
Choice C rationale
Aspiration is a common problem for people with dysphagia, a condition that can occur after a stroke. It occurs when something you’ve swallowed enters the airway and lungs. Normally, aspiration causes a violent cough, but a stroke can reduce sensation. In this case, you may not know you’re aspirating (silent aspiration)5.
Choice D rationale
Gastroesophageal reflux disease (GERD) is not a common complication of difficulty swallowing after a stroke. GERD is a chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining.

A. This is likely related to new-onset dementia. B. This is likely related to new-onset schizophrenia. C. This is likely related to new-onset hepatic encephalopathy. D. This is likely related to a new-onset UTI.

Correct Answer is C

Explanation

Choice C rationale
Hepatic encephalopathy is a condition that can cause confusion or delirium in patients with end-stage liver disease and increasing ascites. It occurs when the liver is unable to remove toxins from the blood, such as ammonia, which can then accumulate in the brain and affect mental function. This condition is common in patients with cirrhosis or end-stage liver disease, and can manifest as confusion, changes in sleep patterns, mood alterations, and, in severe cases, coma.
Choice A rationale
While dementia can cause confusion and changes in mental status, it is typically a progressive condition that develops over time. In the context of a patient with end-stage liver failure and

increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice B rationale
Schizophrenia is a chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It is not typically associated with end-stage liver disease or ascites. In the context of a patient with end-stage liver failure and increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice D rationale
While a urinary tract infection (UTI) can cause confusion, especially in older adults, it would not typically be the primary suspect in a patient with end-stage liver failure and increasing ascites. In such a patient, hepatic encephalopathy is a more likely cause of confusion or delirium.

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

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 care for a patient who had a stroke and is experiencing difficulty swallowing. Which of the following complications should the nurse monitor for in this patient?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A patient diagnosed with Hepatitis A is concerned about the risk of transmission to other family members. What is the primary mode of Hepatitis A transmission that the nurse should mention in the response?

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

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?

A nurse is admitting a patient who has active tuberculosis to a room in a medical-surgical unit. Which of the following room assignments should the nurse make for the patient?

A nurse is educating a patient who has long-term symptoms of GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include in the educational materials?

A nurse is preparing a care plan for a patient who is about to receive a transfusion of packed red blood cells. What should be the maximum duration for the total infusion time?

A nurse is reviewing the medical record of a patient who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?