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 B

Explanation

Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.

Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.

Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.

Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.

A. Reduces the inflammatory process, improving nerve transmission and function. B. Slows the scarring in the myelin sheath, improving muscle tone and strength. C. Increases the amount of dopamine available for muscles to function correctly. D. Acts as an antiseizure medication, reducing the tremors caused by the disease.

Correct Answer is C

Explanation

Choice A reason: Carbidopa-levodopa does not primarily reduce the inflammatory process. Its main action is related to dopamine synthesis and availability.

Choice B reason: Carbidopa-levodopa does not slow scarring in the myelin sheath. This medication targets dopamine deficiency, not myelin health.

Choice C reason: Carbidopa-levodopa increases the amount of dopamine in the brain. Dopamine is a neurotransmitter that is crucial for motor control. Parkinson's disease is characterized by dopamine deficiency, and this medication helps to replenish dopamine levels, improving muscle function and reducing symptoms like tremors and stiffness.

Choice D reason: Carbidopa-levodopa is not an antiseizure medication. It is specifically used to manage the motor symptoms of Parkinson's disease by addressing dopamine deficiency.

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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

The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

Correct Answer is B

Explanation

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?

Correct Answer is C

Explanation

The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary modification should the nurse include in the teaching plan?

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

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