The nurse is assessing a patient's bowel sounds.
The nurse does not hear anything for 30 seconds.
How should the nurse document this finding?

Choice A rationale

While it is important to inform the physician about the delay in the TPN solution, the immediate priority is to maintain the patency of the central venous catheter and prevent hypoglycemia. Calling the MD should occur after taking steps to address the immediate risk.

Choice B rationale

Giving the patient a high-protein snack will not address the immediate issue of the TPN running out and the risk of hypoglycemia associated with the abrupt cessation of a high-glucose solution. TPN provides a significant amount of glucose, and suddenly stopping it can lead to a drop in blood sugar.

Choice C rationale

Hanging a bag of 10% dextrose solution (D10W) is the most appropriate immediate action. This will provide a continuous source of glucose to prevent hypoglycemia while waiting for the new TPN bag from the pharmacy. D10W is often used as a bridge solution in this situation. Normal blood glucose levels are typically 70-110 mg/dL.

Choice D rationale

Flushing the line and waiting for the pharmacy to supply the next bag without infusing any solution puts the patient at significant risk for hypoglycemia and can also lead to catheter occlusion. Maintaining a continuous infusion, even of D10W, is crucial. .

Choice A rationale

Normoactive bowel sounds are the typical, intermittent gurgling sounds heard during a bowel assessment, indicating normal peristalsis and intestinal activity. The absence of any sounds for 30 seconds suggests a significant reduction or cessation of this activity, which is not consistent with normoactive findings.

Choice B rationale

Hypoactive bowel sounds are characterized by infrequent and faint gurgling sounds, indicating a decrease in intestinal motility. While a pause of 30 seconds without any sounds might precede hypoactive sounds, the complete absence of sounds for this duration is more indicative of a further reduction in bowel activity than simply hypoactivity.

Choice C rationale

Absent bowel sounds are documented when no bowel sounds are heard after listening in each of the four abdominal quadrants for a specified period, typically ranging from 2 to 5 minutes per quadrant. A 30-second period without any sounds in one area is a significant finding that should be documented as absent in that specific quadrant, warranting further assessment.

Choice D rationale

Hyperactive bowel sounds are loud, high-pitched, and frequent gurgling sounds, often described as "borborygmi" or stomach rumbling. These sounds indicate increased intestinal motility, which is the opposite of the finding of no bowel sounds for 30 seconds.