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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Blood-tinged: Pancreatic cancer does not typically cause rectal bleeding.

B. Clay: Blockage of the bile duct leads to pale (clay-colored) stools due to lack of bilirubin.

C. Brown: Normal stools are brown due to bilirubin metabolism.

D. Chalky: Chalky is not a typical term used for stool description in pancreatic cancer.

A. Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr B. Insert a nasogastric tube C. Draw a basic metabolic panel D. Ambulate in the hallway

Correct Answer is B

Explanation

A. Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr: Fluid resuscitation is important, but potassium should not be administered until electrolyte levels are assessed. Also, potassium administration in a client with a bowel obstruction requires caution due to the risk of hyperkalemia if renal function is impaired.

B. Insert a nasogastric tube: A nasogastric (NG) tube is essential in managing bowel obstruction as it helps decompress the stomach, relieve pressure, and prevent aspiration. This should be done first to stabilize the client.

C. Draw a basic metabolic panel: Checking electrolyte imbalances is important but should be done after stabilizing the client with NG tube insertion.

D. Ambulate in the hallway: Ambulation is contraindicated in acute bowel obstruction due to the risk of worsening symptoms such as nausea, vomiting, and severe pain.

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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?

Nursing Test Bank

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