ExamTopics Logo
Mail Us[email protected]
Menu
Test-Prep Discussions
exam questions

Exam NCLEX-RN All Questions

View all questions & answers for the NCLEX-RN exam
Go to Exam

Exam NCLEX-RN topic 4 question 150 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 150
Topic #: 4
[All NCLEX-RN Questions]

A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric
(NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

  • A. It is determined that he has no signs of wound infection
  • B. He is able to eat a full meal without evidence of nausea or vomiting
  • C. The nurse can detect bowel sounds in all four quadrants
  • D. His blood pressure returns to its preoperative baseline level or greater
Show Suggested Answer Hide Answer
Suggested Answer: C 🗳️
(A) The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. (B) Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. (C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. (D) Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
by [deleted] at March 10, 2025, 6:52 a.m.

Comments

Chosen Answer:
This is a voting comment (?). It is better to Upvote an existing comment if you don't have anything to add.
Switch to a voting comment New
Submit Cancel
Currently there are no comments in this discussion, be the first to comment!
Community vote distribution
A (35%)
C (25%)
B (20%)
Other
Most Voted
A voting comment increases the vote count for the chosen answer by one.

Upvoting a comment with a selected answer will also increase the vote count towards that answer by one. So if you see a comment that you already agree with, you can upvote it instead of posting a new comment.

SaveCancel