The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the client's abdomen and notes that there are no bowel sounds. What action does the nurse take?
a. Position the client on the left side with the bed flat.
b. Insert a nasogastric tube to low intermit-tent suction.
c. Palpate the bladder and measure abdo-minal girth.
d. Document the finding and continue to monitor.
D
Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.
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