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 D

Explanation

Choice A rationale

While an elevated serum ammonia level can indicate liver dysfunction, it is not typically a contraindication for liver biopsy. Ammonia is a byproduct of protein metabolism and is normally converted into urea by the liver, which is then excreted in the urine. Elevated levels can occur in liver disease, but they are not typically a direct concern in the context of a liver biopsy.
Choice B rationale
A hemoglobin level of 11 g/dL is slightly low, but it is not typically a contraindication for a liver biopsy. Hemoglobin is the protein in red blood cells that carries oxygen. While a low hemoglobin level can indicate anemia, it would not typically prevent a patient from undergoing a liver biopsy.
Choice C rationale
A white blood cell count of 14.2 x 103/uL is slightly elevated, indicating a possible infection or inflammation. However, this would not typically be a contraindication for a liver biopsy.
Choice D rationale
A prothrombin time of 32 seconds is significantly prolonged, indicating a potential problem with blood clotting. This would be a major concern for a nurse caring for a patient scheduled for a liver biopsy, as the procedure involves inserting a needle into the liver and could lead to bleeding. Patients with a prolonged prothrombin time are at an increased risk of bleeding complications.

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 patient is scheduled for a liver biopsy. Which laboratory result would be of most concern to the nurse?

Correct Answer is D

Explanation

A nurse is educating a patient who has been prescribed a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following reasons for the use of the nasogastric tube should the nurse include in the teaching?

Correct Answer is D

Explanation

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