The nurse is performing an abdominal assessment on a patient who just returned from surgery following a colon resection. The nurse identifies that bowel sounds are not audible. Which action by the nurse would be most appropriate?
Ask a peer to validate the results.
Reassess in hours
Document the findings
Neely the healthcare provider.
The Correct Answer is C
A. Ask a peer to validate the results: While confirming findings with a colleague can sometimes be helpful, it is not necessary in this case. Postoperative ileus is common, and the priority is monitoring and documentation.
B. Reassess in hours: The nurse should reassess bowel sounds periodically, but the specific timeframe should be based on hospital policy and clinical judgment. Bowel sounds may be absent for hours to days postoperatively.
C. Document the findings: Documentation is critical as absent bowel sounds are expected after abdominal surgery. However, it should be accompanied by continued monitoring.
D. Notify the healthcare provider: Absence of bowel sounds immediately post-op is not necessarily an emergency. However, if accompanied by other signs (e.g., distention, vomiting, severe pain), notifying the provider would be warranted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Total volume to be infused = 50 mL
Infusion rate = 2 mL/min
Time required = Total volume / Infusion rate
= 50 mL ÷ 2 mL/min
= 25 minutes
Correct Answer is A
Explanation
A. Obstruction of the bile duct: Biliary cirrhosis (now called primary or secondary biliary cholangitis) can occur due to prolonged bile duct obstruction, leading to liver damage and cirrhosis.
B. Hepatitis C: Hepatitis C can cause cirrhosis, but it is not a direct cause of biliary cirrhosis. Instead, it leads to post-viral cirrhosis.
C. Hepatotoxic medications: Certain medications (e.g., acetaminophen overdose) can cause liver damage, but they do not specifically cause biliary cirrhosis.
D. Excessive alcohol consumption: Alcohol abuse can cause alcoholic cirrhosis, but not biliary cirrhosis.
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