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 B

Explanation

A. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.

A. Teaching foot care to a client who has diabetes B. Performing monthly breast self-examinations C. Providing a community program on stress reduction D. Referring a client who has had a mastectomy to a support group

Correct Answer is B

Explanation

A. Teaching foot care to a client with diabetes is an example of tertiary prevention, which aims to manage and improve quality of life for individuals with chronic diseases.
B. Performing monthly breast self-examinations is an example of secondary prevention, which involves early detection of diseases to provide timely treatment.
C. Providing a community program on stress reduction is an example of primary prevention, which aims to prevent disease before it occurs.
D. Referring a client to a support group after a mastectomy is an example of tertiary prevention, focusing on rehabilitation and support after a significant health event.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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