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. Maintain a patent airway and prevent aspiration: While maintaining a patent airway is always important, esophageal varices do not typically cause aspiration unless they rupture. This choice would be a priority in an acute bleed, not in a stable client.

B. Monitor the effects of antihypertensive medications: Beta-blockers (e.g., propranolol) are commonly prescribed to reduce portal hypertension, preventing variceal rupture. Monitoring the effects of these medications is crucial in maintaining hemodynamic stability.

C. Prepare the client for immediate portal shunting surgery: Surgical shunting is considered for refractory cases with severe, recurrent bleeding. A client with stable varices does not require immediate surgery.

D. Perform fecal occult testing on all stools: Esophageal varices cause upper GI bleeding, which manifests as hematemesis or melena, not occult blood in the stool.

Correct Answer is ["45"]

Explanation

30g x 10g ×15ml=45ml

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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

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with stable esophageal varices. Which of the following actions is most important?

Correct Answer is B

Explanation

The nurse is to administer 30gm of lactulose to a client. The medication is supplied as 10gm/15ml. How many mL would you give to the client.

Correct Answer is ["45"]

Explanation

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