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 presence of flatus (gas) is a positive sign that the patient's gastrointestinal tract is resuming normal function after a bowel resection surgery. Flatus production indicates that peristalsis and normal bowel motility are returning, allowing gas to move through the intestine. This is an important milestone in the postoperative recovery process, as it suggests the return of normal bowel function. The other options provided are not indicative of the return of normal gastrointestinal function.

Correct Answer: C

Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.

Correct Answer: C

Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.

Correct Answer: C

Rationale: Option C, which is to toilet the patient according to his pre-illness schedule, whether or not he feels the urge, is the best intervention by the nurse to help reduce episodes of bowel incontinence in this patient with subarachnoid hemorrhage. This strategy can help establish a routine and promote regular bowel movements, which may reduce the likelihood of bowel incontinence episodes. Asking the patient frequently if he has to have a bowel movement (Option A) may not be effective, as the patient may not always be able to accurately communicate their needs due to the underlying condition. Placing incontinence pads on the patient's bed and chair (Option B) may manage the consequences of incontinence but does not address the root cause. While taking care not to embarrass the patient when incontinent episodes occur (Option D) is important for maintaining the patient's dignity, it does not directly address the issue of reducing bowel incontinence episodes.

Correct Answer: A

Rationale: The medulla oblongata, located in the brainstem, is responsible for controlling essential autonomic functions such as breathing, heart rate, and blood pressure. Specifically, the medulla regulates the rhythm and depth of breathing by sending signals to the respiratory muscles, including the diaphragm and intercostal muscles. In response to changing levels of oxygen and carbon dioxide in the blood, the medulla adjusts the breathing rate to maintain proper oxygenation of the body tissues. Damage to the medulla can result in respiratory failure, highlighting its critical role in controlling breathing.