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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Elevated WBC is not typically associated with ITP, which primarily affects platelet counts.
B. Fever may indicate infection but is not specific to ITP.
C. Fatigue can occur in clients with ITP due to anemia or chronic illness but is not specific to the condition.
D. Ecchymosis (bruising) is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies.

A. Increase intake of low fiber foods. B. Avoid drinking hot liquids. C. Include probiotic foods in the daily diet. D. Increase fluid intake to 1500 mL daily. E. Increase daily exercise. F. Increase daily exercise.

Correct Answer is ["C","D","E"]

Explanation

A. Increasing the intake of high-fiber foods, not low-fiber ones, as fiber helps to soften stools and promote bowel movements.
B. Drinking warm or hot liquids can stimulate bowel movements, so they should not be avoided.
C. Including probiotic foods in the diet can help maintain a healthy gut flora, which is beneficial for digestion and preventing constipation.
D. It is crucial to increase fluid intake, aiming for at least 1500 mL daily, to help soften the stool and support regular bowel movements.
E. Increasing daily exercise, especially walking, can stimulate the muscles involved in the digestive process and help prevent constipation.

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A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Nursing Test Bank

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