The nurse is caring for a client who is one day post op after having abdominal surgery. While auscultating bowel sounds for a full one minute, the nurse hears 3 bowel sounds. The nurse would chart this as bowel sounds.
hyperactive
active
hypoactive
absent
The Correct Answer is C
In a postoperative client one day after abdominal surgery, hearing only 3 bowel sounds in one minute indicates hypoactive bowel sounds. Normal bowel sounds are typically described as "active" and occur at a rate of 5 to 30 per minute. Hypoactive bowel sounds are decreased in frequency, often occurring less than 5 per minute, and may indicate decreased gastrointestinal motility, which is common after abdominal surgery due to factors such as anesthesia, pain medication, and bowel manipulation during surgery.
A. Hyperactive: Hyperactive bowel sounds, also known as "borborygmi," are increased in frequency and intensity. They are often loud, gurgling sounds and may indicate increased gastrointestinal motility or the presence of diarrhea. This description does not fit the scenario described.
B. Active: While "active" bowel sounds are within the normal range, hearing only 3 bowel sounds in one minute suggests decreased frequency, indicating hypoactivity rather than normal activity.
C. Hypoactive: Hypoactive bowel sounds are decreased in frequency, occurring less than 5 per minute. This finding is commonly observed in postoperative clients due to factors such as anesthesia and opioid pain medication.
D. Absent: Absent bowel sounds are concerning and may indicate ileus or bowel obstruction. In this scenario, hearing 3 bowel sounds indicates some bowel motility, ruling out the classification of absent bowel sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Isotonic fluid helps the client feel less thirsty when they are NPO: While isotonic fluids can help maintain hydration status, they do not directly address the sensation of thirst. Isotonic fluids replace extracellular fluid volume and help maintain electrolyte balance but do not affect the sensation of thirst.
B. This type of IV hydration replaces blood volume without affecting intracellular fluid: This is the correct property of isotonic fluid replacement. Isotonic IV fluids have a similar osmolarity to extracellular fluid and thus replace fluid volume without significantly impacting the distribution of water between intra- and extracellular compartments. They are effective for expanding intravascular volume without causing a significant shift of water into or out of cells.
C. Isotonic IV hydration can cause cells to burst if given too rapidly: Isotonic IV fluids have the same osmotic pressure as blood plasma and therefore do not cause cells to burst when administered at appropriate rates. It is hypertonic solutions that can cause cells to shrink or swell due to osmotic imbalances.
D. This type of IV fluid must be given in an intensive care setting with frequent monitoring of the client's vital signs: While isotonic fluids are commonly used in various clinical settings, including intensive care, they do not inherently require administration in an intensive care setting with frequent monitoring of vital signs. Isotonic fluids are often administered in routine medical-surgical settings for various fluid balance problems.
Correct Answer is C
Explanation
A. The client should not be asked about religion or spirituality: This option is not appropriate. Religion and spirituality are important aspects of holistic care and should be addressed based on the client's preferences and needs. Avoiding discussions about religion or spirituality based on the client's statement may overlook opportunities for supportive care.
B. The client has abandoned religion due to illness: There is no evidence to suggest that the client has abandoned religion due to illness based solely on the statement provided. Assuming such a conclusion without further assessment would be inappropriate and potentially inaccurate.
C. The client could be interviewed about personal experiences that guide their life: This is the correct interpretation. The client's statement indicates that they identify as spiritual but do not adhere to a specific religious denomination. This suggests that the client may have personal beliefs, values, or experiences that guide their life and worldview. The nurse can explore these aspects through open-ended questions to gain insight into the client's spiritual needs and preferences.
D. The client does not believe in a higher power: There is no indication from the client's statement that they do not believe in a higher power. The statement simply suggests that the client does not affiliate with a specific religious denomination, but it does not necessarily imply atheism or disbelief in a higher power.
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