During the postoperative assessment of a client who had an appendectomy 36 hours ago, the nurse is unable to hear any bowel sounds. The client denies passing flatus. What action by the nurse is indicated?
1. Encourage the client to increase fluid intake to promote peristalsis
2. Encourage the client to increase solid food intake to promote peristalsis
3. Withhold food and fluid intake until intestinal motility has returned
4. Encourage the client to slow the amount of oral intake
3. Withhold food and fluid intake until intestinal motility has returned
Rationale:
After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is not experiencing peristalsis. Oral intake must be withheld during this time.
You might also like to view...
The nurse plans to collect data on a client who has been admitted with mild respiratory distress secondary to pulmonary edema. When planning the sequence of the assessment, the nurse would do which of the following?
1. Plan to assess the client to minimize position changes. 2. Perform the respiratory assessment first. 3. Assess from head-to-toe. 4. Begin by assessing cardiac status.
A community health nurse is aware of the fact that patterns of HIV infection have changed significantly since the disease was first identified in the 1980s
Which of the following demographic groups represents the highest proportion of new HIV diagnoses? A) Heterosexual women of low socioeconomic status B) Men who have sex with men (MSM) C) Injection drug users D) Blood transfusion recipients
Development of varicose veins is caused by increased pressure on leg veins as a result of the weight of the uterus. Which of the following is not recommended for pregnant women?
A) Elevate feet whenever possible. B) Wear support hose. C) Wear flat shoes with arch support. D) Wear knee-high stockings.
The nurse is caring for a 41-weeks'-gestation infant born yesterday. The newborn's hematocrit is 75%. The best action by the nurse based on this finding is to:
1. Inform the parents that their baby has an abnormal lab value. 2. Call the physician and report the hematocrit level. 3. Notify the blood bank that a transfusion will be required. 4. Increase breastfeeding frequency, and supplement between feedings.