When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?

Withhold further opioid analgesics.

Obtain a prescription for a laxative.

Document the assessment finding.

Prepare to insert a nasogastric tube.

Answer and Explanation

The Correct Answer is C

Choice A reason: Withholding further opioid analgesics might be considered if the lack of bowel sounds is due to opioid-induced ileus. However, this is not the immediate action the nurse should take. The nurse should first document the finding and continue to assess the client's condition.

Choice B reason: Obtaining a prescription for a laxative might be appropriate if the client is experiencing constipation. However, administering a laxative without further assessment and documentation of the bowel sounds could lead to complications. The nurse should document the finding first and then collaborate with the healthcare provider for further interventions.

Choice C reason: Documenting the assessment finding is the most appropriate initial action. This ensures that the lack of bowel sounds is recorded in the client's medical record, which is crucial for ongoing monitoring and communication with the healthcare team. Proper documentation also helps in tracking changes in the client's condition and making informed decisions about subsequent care.

Choice D reason: Preparing to insert a nasogastric tube might be necessary if the client develops symptoms of bowel obstruction or other complications. However, this action should follow the documentation and further assessment of the client's condition. The nurse should document the finding first to provide a basis for any further interventions.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Skin elasticity is not an immediate indicator of the client's response to diuretic treatment. It is more commonly used to assess hydration status and overall skin condition rather than the effectiveness of a diuretic.

Choice B reason: Pain scale is important for assessing the client's comfort level, but it does not directly measure the effectiveness of furosemide in improving respiratory status and reducing fluid overload.

Choice C reason: Lung sounds should be assessed to determine if there is an improvement in the client's respiratory status after the administration of furosemide. Reduction in wheezes and crackles would indicate decreased fluid in the lungs and improved breathing.

Choice D reason: Oxygen saturation is crucial to monitor as it provides information on the client's oxygenation status. An improvement in oxygen saturation levels indicates effective relief of pulmonary congestion and better gas exchange after the diuretic treatment.

Choice E reason: Urinary output is a direct measure of the effectiveness of furosemide, as it promotes diuresis to remove excess fluid from the body. Increased urinary output indicates that the medication is working to reduce fluid overload.

A. Haematocrit of 30% (0.30 volume fraction). B. Facial puffiness and periorbital enema. C. Further decline in level of consciousness. D. Cold and dry skin.

Correct Answer is C

Explanation

Choice A reason: A haematocrit of 30% is below the normal range and indicates anaemia, which is common in hypothyroidism. However, it does not require immediate intervention compared to a decline in consciousness.

Choice B reason: Facial puffiness and periorbital enema are common signs of hypothyroidism but do not require immediate intervention. They are more indicative of chronic, rather than acute, issues.

Choice C reason: A further decline in level of consciousness is critical and warrants immediate action. It can indicate a myxoedema coma, a severe complication of hypothyroidism that is life-threatening and requires urgent treatment.

Choice D reason: Cold and dry skin is a common symptom of hypothyroidism but does not require immediate intervention compared to a decline in consciousness.

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When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","E"]

Explanation

A client who has a history of hypothyroidism was admitted with lethargy and confusion. Which additional finding warrants immediate action by the nurse?

Correct Answer is C

Explanation

During a home visit, the nurse should evaluate the effectiveness of a client's treatment for chronic obstructive pulmonary disease (COPD) by assessing for which primary symptom?

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

The nurse is developing a plan of care for a client who reports frequent urination and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client?

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?