A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
Auscultates bowel sounds for 3 to 5 min
Clamps the NG tube during auscultation
Performs auscultation between meals
Palpates the abdomen prior to performing auscultation.
The Correct Answer is D
Rationale:
A. Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamping the NG tube prevents false bowel sounds from the tube.
C. Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A positive Western blot test confirms HIV infection but does not provide immediate information on the client's immune status.
B. Platelets within the normal range are important but do not directly indicate the client's immune status or HIV progression.
C. CD4-T-cell count is crucial for monitoring HIV progression and immune function. A low count indicates immunosuppression and increased risk of opportunistic infections.
D. WBC count is important but does not specifically indicate the client's HIV status or immune function related to HIV.
Correct Answer is ["B","D","E"]
Explanation
A. Urine-specific gravity greater than 1.030 indicates concentrated urine, suggesting dehydration, not fluid volume excess.
B. A bounding pulse is a sign of fluid volume excess.
C. Swelling at the IV site indicates infiltration, not systemic fluid volume excess.
D. Crackles upon auscultation of the lungs indicate fluid accumulation in the lungs, a sign of fluid volume excess.
E. Pitting edema is a sign of fluid volume excess, indicating fluid retention in the tissues.
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