A 58-year-old patient is going home today. The nurse does her final assessment of the patient. Which of the following would be considered a normal finding?
Bowel sounds 5-30 per minute.
Capillary refill of greater than 3 seconds.
Respiratory rate of 25
Heart rate of 10
The Correct Answer is C
The normal range for respiratory rate in adults is typically between 12 to 20 breaths per minute, butsome individuals may have a slightly higher or lower respiratory rate within the normal range.
Options a and b are incorrect. Bowel sounds of 5-30 per minute are within the normal range, but this finding alone does not indicate that the patient is ready to go home. Capillary refill of greater than 3 seconds is considered abnormal and may indicate poor peripheral perfusion.
Option d is also incorrect. A heart rate of 10 is extremely low and would be considered bradycardia. This could indicate an underlying medical issue and would require further assessment and intervention before the patient is discharged.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nurses are mandated reporters, meaning they are legally required to report any suspected or confirmed cases of child, elder, or vulnerable adult abuse or neglect to the appropriate authorities, such as child protective services or adult protective services. This duty applies regardless of whether the abuse or neglect was disclosed by the victim or observed by the nurse.
While nurses may choose to involve family members or refer the individual to social services, these actions do not replace the legal obligation to report abuse or neglect. Failure to report can result in legal and professional consequences for the nurse.
Correct Answer is B
Explanation
The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be affected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.
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