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 A

Explanation

Choice A reason: Joining a group weight loss program is important for the client's overall health, particularly due to obesity being a significant risk factor for gallbladder disease. Weight loss can help decrease the likelihood of gallstone formation and other gallbladder-related issues. Participation in a weight loss program can also provide support and structured guidance for achieving a healthier weight.

Choice B reason: Beginning a smoking cessation class is beneficial for the client's health, as smoking is a risk factor for many diseases, including gallbladder issues. However, in the context of reducing gallbladder disease risk, weight loss would have a more direct and immediate impact, making it the primary focus for intervention.

Choice C reason: Considering hormone replacement therapy may be relevant for managing symptoms associated with menopause. However, it is not directly related to the risk reduction for gallbladder disease. Hormone replacement therapy should be discussed with a healthcare provider to weigh the benefits and risks.

Choice D reason: Scheduling rest periods after eating is generally helpful for digestion and comfort, but it does not directly address the key risk factors for gallbladder disease in this client, such as obesity and diet. Addressing these primary risk factors through weight loss would be more effective in reducing the client's risk.

A. Reduce the client's interaction with others during the day. B. Awaken the client for reality checks every 4 hours at night. C. Clarify reality with the client about delusional thoughts. D. Use distraction and therapeutic communication skills.

Correct Answer is D

Explanation

Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.

Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.

Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.

Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.

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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

A client who is postmenopausal, obese, and is a smoker, has developed an intolerance to fatty foods and believes she is at risk for developing gallbladder problems. Which instruction should the nurse provide to help reduce the client's risk for gallbladder disease?

Correct Answer is A

Explanation

The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

Correct Answer is D

Explanation

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