Nokea
The nurse is performing an initial postoperative assessment on the client following upper GI surgery. The client has an NG tube to low intermittent suction. To best assess the client for the presence of bowel sounds, which intervention should the nurse implement?
- A. Start auscultating to the left of the umbilicus.
- B. Turn off the NG suction before auscultation.
- C. Use the bell of the stethoscope for auscultation.
- D. Empty the drainage canister before auscultation.
Correct Answer: B
Rationale: A. When the client has hypoactive bowel sounds, which would be expected in a postsurgical client, the nurse should begin listening over the ileocecal valve in the right lower abdominal quadrant rather than to the left of the umbilicus. The ileocecal valve normally is a very active area. B. When listening for bowel sounds on the client who has an NG tube to suction, the nurse should turn off the suction during auscultation to prevent mistaking the suction sound for bowel sounds. C. The diaphragm of the stethoscope should be utilized for bowel sounds. The bell of the stethoscope should be utilized for abdominal vascular sounds, such as bruits. D. There is no reason to empty the canister before auscultation.
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The client with a duodenal ulcer is ready for discharge. Which statement made by the client indicates a need for more teaching about his diet?
- A. It's a good thing I gave up drinking alcohol last year.'
- B. I will have to drink lots of milk and cream every day.'
- C. I will stay away from cola drinks after I am discharged.'
- D. Eating three nutritious meals and snacks every day is okay.'
Correct Answer: B
Rationale: Milk and cream cause rebound acidity and are not recommended for ulcer clients. Avoiding alcohol and cola, and eating regular meals and snacks, are appropriate.
The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care?
- A. Administer a laxative of choice.
- B. Encourage the client to increase oral fluids.
- C. Encourage the client to take deep breaths.
- D. Maintain a patent nasogastric tube.
Correct Answer: D
Rationale: Maintaining a patent NG tube decompresses the bowel in paralytic ileus, preventing complications. Laxatives and oral fluids are contraindicated, and deep breathing is unrelated.
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
- A. The client who had an inguinal hernia repair and has not voided in four (4) hours.
- B. The client who was admitted with abdominal pain who suddenly has no pain.
- C. The client four (4) hours postoperative abdominal surgery with no bowel sounds.
- D. The client who is one (1) day postappendectomy and is being discharged.
Correct Answer: B
Rationale: Sudden resolution of abdominal pain may indicate perforation (e.g., appendicitis), a life-threatening emergency requiring immediate assessment. Urinary retention, absent bowel sounds, and discharge are less urgent.
The male client had abdominal surgery and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis?
- A. Absent bowel sounds and potassium level of 3.9 mEq/L.
- B. Abdominal cramping and hemoglobin of 14 g/dL.
- C. Profuse diarrhea and stool specimen shows Campylobacter.
- D. Hard, rigid abdomen and white blood cell count 22,000/mm3.
Correct Answer: D
Rationale: A hard, rigid abdomen and elevated WBC count (22,000/mm3) indicate peritonitis due to peritoneal inflammation and infection. Absent bowel sounds are nonspecific, cramping with normal hemoglobin is less indicative, and diarrhea with Campylobacter suggests gastroenteritis.
The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching?
- A. In the future I will eat a banana every time I take the medication.
- B. I don't have to have a bowel movement every day.
- C. I should limit the fluids I drink with my meals.
- D. If I feel sluggish, I will eat a lot of cheese and dairy products.
Correct Answer: B
Rationale: Understanding that daily bowel movements are not necessary reflects proper teaching to reduce cathartic overuse. Bananas, fluid limits, and dairy are incorrect.