The nurse is caring for a client who is 4 hours post-op after an open cholecystectomy. The nurse would expect the client's bowel sounds to be:

Normoactive.

Absent or hypoactive.

Hyperactive.

Borborygmi.

Answer and Explanation

The Correct Answer is B

Choice B rationale

After an open cholecystectomy, bowel sounds are typically absent or hypoactive due to the effects of anesthesia and the manipulation of the intestines during surgery. It takes time for normal bowel function to resume.

Choice A rationale

Normoactive bowel sounds are not expected immediately after abdominal surgery due to the temporary paralysis of intestinal motility caused by anesthesia and surgical manipulation.

Choice C rationale

Hyperactive bowel sounds are uncommon after surgery. They are more often associated with conditions like gastroenteritis or bowel obstruction rather than the immediate postoperative period of an open cholecystectomy.

Choice D rationale

Borborygmi, or loud, rumbling bowel sounds, are not expected after abdominal surgery. These sounds can indicate increased bowel activity, which is not typical in the immediate postoperative phase following an open cholecystectomy.

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Correct Answer is D

Explanation

Choice A rationale

Urine specific gravity of 1.035 indicates dehydration, which is concerning but not the most critical issue in a client with a bowel obstruction.

Choice B rationale

Colicky pain is typical of bowel obstruction as the intestines try to move contents past the obstruction, and while concerning, it is expected.

Choice C rationale

Serum sodium of 132 mEq/L indicates mild hyponatremia, which is concerning but not immediately life-threatening in the context of bowel obstruction.

Choice D rationale

Frank blood in the N/G suction container indicates possible bowel ischemia or perforation, which requires immediate intervention and is the most concerning finding.

A. Hypoactive bowel sounds. B. Reports intermittent incisional pain 7 on 0-10 scale. C. Blood pressure 110/70, heart rate 86. D. Increased restlessness.

Correct Answer is D

Explanation

Choice A rationale

Hypoactive bowel sounds are common post-operatively due to anesthesia and immobility, so they are not the most concerning immediate finding.

Choice B rationale

Intermittent incisional pain rated 7/10 is significant but expected post-operatively, and manageable with pain control measures.

Choice C rationale

Blood pressure of 110/70 and heart rate of 86 are within normal ranges, so these are not alarming post-operative signs.

Choice D rationale

Increased restlessness can indicate pain, anxiety, or potentially worsening condition, making it the most concerning and requiring immediate attention.

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The nurse is caring for a client who is 4 hours post-op after an open cholecystectomy. The nurse would expect the client's bowel sounds to be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which finding would most concern the nurse when caring for a client diagnosed with a bowel obstruction?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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