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. Emphasizing the significance of the information may not address the cultural behavior of avoiding direct eye contact.
B. Continuing with the discussion respects the client's cultural behavior, as some cultures view direct eye contact as disrespectful.
C. Stopping the instructions to see what is on the floor may misunderstand the client's cultural behavior.
D. Moving closer for eye contact may make the client uncomfortable if their culture views direct eye contact as inappropriate.

A. Adjust the prescribed weights every shift. B. Monitor peripheral pulses in the affected extremity. C. Examine the skin under the traction splint. D. Assess the temperature of the affected extremity. E. Position weights against the foot of the bed.

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

Explanation

A. Traction weights are typically set by the physician and shouldn't be adjusted by the nurse unless specifically ordered.
B. Monitoring peripheral pulses helps assess circulation and neurovascular status in the affected extremity.
C. Examining the skin under the traction splint is essential to assess for skin integrity and prevent complications like pressure ulcers.
D. Assessing the temperature of the affected extremity helps detect signs of circulatory impairment or infection.
E. Positioning weights against the foot of the bed is not a correct action for managing Buck's traction.

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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

A nurse is providing dietary teaching for a client who is Asian-American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care?

Correct Answer is B

Explanation

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

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