100. One day after surgery for intestinal resection, a client has no bowel sounds. Which action should a nurse take?
100. One day after surgery for intestinal resection, a client has no bowel sounds. Which action should a nurse take?
. Take the vital signs and notify the physician.
. Record this expected finding.
. Check rectally for impacted stool.
. Perform abdominal massage.
Test-Taking Tip
The key word is "expected." Select an option that is realistic 24 hours after having been NPO (no stool will have formed in this short time period) for abdominal surgery (and massage would be painful).
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
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Answer 1 is incorrect because the absence of bowel sounds is expected on the first postoperative day. No action is required. Answer 2 is correct because paralytic ileus is expected after major abdominal surgery. The absence should be recorded in the medical record. Answer 3 is incorrect because the absence of bowel sounds is expected. It does not indicate impaction. Answer 4 is incorrect because the absence of bowels sounds is expected. Massage is not indicated.