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 D
Explanation
A. Closed-ended questions may limit the information gathered from the client. Open-ended questions are more appropriate for exploring sensitive topics like STIs.
B. Referring a client to genetic counseling is not typically indicated solely based on a history of STIs.
C. A client's reproductive health history, including past and present STIs, is crucial for comprehensive counseling and treatment planning.
D. Asking about the client's exposure to past or present STIs is important for assessing risk factors, providing appropriate counseling, and guiding testing and treatment decisions.
Correct Answer is A
Explanation
A. A PT of 45 seconds is prolonged and indicates a potential risk of bleeding due to excessive anticoagulation with warfarin. The nurse should notify the provider for further evaluation and adjustment of the warfarin dosage.
B. Platelets within the normal range (150,000-400,000/mm3) are adequate and do not require immediate provider notification.
C. Hematocrit of 44% is within the normal range for adults and does not indicate an urgent need for provider notification.
D. Hemoglobin of 16 g/dL is within the normal range for adults and does not require immediate provider notification.
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