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. Waiting until after the procedure to inform the provider is not appropriate for discussing end-of-life wishes.
B. The seriousness of the procedure does not determine the necessity of a DNR request; it's the client's right to express this choice.
C. While spiritual support can be helpful, discussing DNR orders typically involves the healthcare team and the client directly.
D. The provider should directly discuss the client's wishes regarding a DNR order to ensure understanding and documentation.
Correct Answer is D
Explanation
A. Administering lorazepam should not be the first action for managing agitation in a client with dementia as it can increase the risk of falls and other complications.
B. Using physical restraints such as raising side rails is not recommended as a first-line intervention and can increase agitation and risks.
C. Applying a vest restraint should be avoided as it restricts the client's movement and can increase agitation and risks.
D. Placing a seat alarm in the client's chair is an appropriate initial intervention to monitor the client's movements and ensure safety while allowing some freedom of movement.
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