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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Occult positive emesis, which indicates the presence of blood in vomit, is a critical finding. It suggests potential gastrointestinal bleeding, which requires immediate medical intervention. This condition can lead to significant blood loss and further complications if not addressed promptly.
Choice B reason: Strong foul-smelling flatus can indicate malabsorption or changes in gut flora, which are common after biliopancreatic diversion. While it can be unpleasant and concerning, it is not as immediately dangerous as gastrointestinal bleeding.
Choice C reason: A report of poor night vision could be related to vitamin A deficiency, which can occur after malabsorptive procedures like BPD. However, it is not an immediate threat compared to the risk of gastrointestinal bleeding.
Choice D reason: Loose bowel movements are common after BPD due to changes in digestion and absorption. While they can contribute to dehydration, they are not as urgent as the presence of blood in vomit.
Correct Answer is ["0.4"]
Explanation
Step 1: Determine the concentration of enoxaparin. 60 mg is equivalent to 0.6 mall
Step 2: Set up the ratio to find how many mL corresponds to 40 mg. (40 mg) ÷ (60 mg) = x ÷ (0.6 mL)
Step 3: Solve for x. x = (40 mg) × (0.6 mL) ÷ (60 mg) x = 24 ÷ 60 x = 0.4 mL
So, the nurse should administer 0.4 mL
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