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 C

Explanation

Rationale:
A. Measuring abdominal girth is not directly related to thrombocytopenia management.
B. Monitoring for WBCs in the urine is not related to thrombocytopenia.
C. Applying pressure to needlestick sites for 10 minutes helps prevent bleeding, which is crucial for clients with thrombocytopenia.
D. Using a rectal thermometer can increase the risk of bleeding and should be avoided in clients with thrombocytopenia.

A. Difficulty moving the upper extremities B. Difficulty hearing some types of sounds C. Stiffness in the lower extremities D. A reddened area over the sacrum

Correct Answer is D

Explanation

A. Difficulty moving the upper extremities may be a result of the stroke but is not a direct complication of immobility.
B. Difficulty hearing some types of sounds is not a typical complication of immobility.
C. Stiffness in the lower extremities can occur but is less urgent than skin breakdown.
D. A reddened area over the sacrum indicates pressure injury, a common and serious complication of immobility that requires immediate attention.

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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 planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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