The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient’s gastrointestinal tract is resuming normal function?

Correct Answer: B

Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.

Correct Answer: C

Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery. A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion. B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion. D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.

Correct Answer: B

Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.

Correct Answer: C

Rationale: The correct answer is C: Toilet the patient according to his pre-illness schedule, whether or not he feels the urge. This intervention helps establish a routine for bowel movements, which can aid in reducing episodes of bowel incontinence. By following the patient's pre-illness schedule, the nurse can help regulate bowel movements and prevent accidents. A: Asking the patient frequently if he has to have a bowel movement may not address the underlying issue of bowel incontinence. B: Placing incontinence pads on the patient's bed and chair is a reactive measure and does not address the root cause of the issue. D: Taking care not to embarrass the patient when incontinent episodes occur is important for emotional support but does not directly address reducing episodes of bowel incontinence.

Correct Answer: C

Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids and foods that are liquid at room temperature. Jello meets this criteria as it is a clear, easily digestible food. Milk (A) is not allowed on a clear liquid diet due to its opaque nature. Orange juice (B) contains pulp and is not considered clear. Ice cream (D) is a solid food and not permitted on a clear liquid diet. Therefore, Jello is the most suitable option for someone on a clear liquid diet.