Which of the following most accurately indicates that a postoperative client’s peristalsis has returned?

Hypoactive bowel sounds in two quadrants during auscultation

The client requests a cup of tea and some toast, showing appetite

Passage of flatus, indicating gastrointestinal motility

Abdominal distention, suggesting gas accumulation

Answer and Explanation

The Correct Answer is C

Choice A reason: Hypoactive bowel sounds in two quadrants suggest reduced peristalsis, indicating persistent postoperative ileus rather than resolution. Normal peristalsis produces active bowel sounds across all quadrants, making this an incorrect indicator of returned gastrointestinal motility in a postoperative client.

Choice B reason: Requesting food indicates appetite but not necessarily peristalsis. Appetite can return before gastrointestinal motility, driven by neurological and hormonal factors. Passage of flatus directly confirms intestinal motility, making appetite a less accurate indicator of peristalsis restoration in this context.

Choice C reason: Passage of flatus is the most accurate indicator of returned peristalsis, as it reflects gastrointestinal motility. Gas movement through the intestines, expelled as flatus, confirms resolution of postoperative ileus, indicating normal bowel function, making this the best sign of recovery.

Choice D reason: Abdominal distention suggests gas accumulation, indicating persistent ileus rather than returned peristalsis. Gas buildup occurs when motility is impaired, causing bloating. Passage of flatus confirms gas movement and restored motility, making distention an incorrect indicator of recovery.

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Correct Answer is C

Explanation

Choice A reason: Notifying the provider delays airway restoration in a tracheostomy dislodgement. The priority is maintaining the airway, as the stoma may close rapidly in a chronic tracheostomy, risking respiratory distress, making immediate tube reinsertion critical over notification.

Choice B reason: Ventilating with a bag-valve-mask provides temporary oxygenation but does not address the dislodged tracheostomy tube. In a chronic tracheostomy, the stoma is the primary airway, and reinserting the tube prevents closure, making ventilation a secondary action.

Choice C reason: Attempting to reinsert a new tracheostomy tube is the priority, as chronic tracheostomy stomas may close rapidly, risking airway loss. Prompt reinsertion maintains patency, preventing respiratory distress or emergent surgical intervention, making this critical for client safety and breathing.

Choice D reason: Covering the stoma with an occlusive dressing risks airway obstruction in a chronic tracheostomy, where the stoma is the primary airway. This could lead to respiratory distress, as the client depends on the tracheostomy, making this incorrect compared to tube reinsertion.

A. Increased respiratory rate B. Clear lung sounds C. Brisk capillary refill D. Decreased pleuritic pain

Correct Answer is B

Explanation

Choice A reason: Increased respiratory rate suggests persistent respiratory distress or ineffective airway clearance in pneumonia, as the body compensates for hypoxia or hypercapnia. This indicates ongoing secretions or inflammation, not a therapeutic response, making it an incorrect indicator compared to clear lung sounds.

Choice B reason: Clear lung sounds indicate effective airway clearance in pneumonia, as treatments like antibiotics and chest physiotherapy reduce secretions and inflammation, allowing normal air movement. This reflects resolved airway obstruction and improved gas exchange, making it the best indicator of a therapeutic response to treatment.

Choice C reason: Brisk capillary refill reflects adequate peripheral perfusion but is unrelated to airway clearance in pneumonia. It does not indicate resolution of secretions or improved lung function, making it an irrelevant marker for evaluating treatment response compared to clear lung sounds, which directly assess airway patency.

Choice D reason: Decreased pleuritic pain suggests reduced pleural inflammation but does not confirm airway clearance. Pain reduction may occur without clearing secretions, the primary issue in pneumonia. Clear lung sounds better indicate successful treatment by demonstrating unobstructed airways and improved respiratory function.

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Which of the following most accurately indicates that a postoperative client’s peristalsis has returned?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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