A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

After palpating the abdomen

Prior to percussing the abdomen

Prior to inspecting the abdomen

After assessing for kidney tenderness

Answer and Explanation

The Correct Answer is B

A.   After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B.   Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C.   Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D.   After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

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Correct Answer is B

Explanation

A. Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.
It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.

A. 1700 B. 1600 C. 1500 D. 1800

Correct Answer is D

Explanation

The total volume to infuse is 1,000 ml over 8 hours, which calculates to a rate of 125 ml/hour (1,000 ml ÷ 8 hr).

By 1400, the client has already received 500 ml (since there is 500 ml remaining in the IV bag).
The infusion has been running for 4 hours (from 1000 to 1400), which means the nurse has infused 500 ml (125 ml/hour × 4 hours).
Since there are 500 ml remaining in the bag, it will take another 4 hours to complete the infusion (500 ml ÷ 125 ml/hour).
Therefore, if the nurse administers the next bag immediately after the current one runs out, it will be at 1800 (1400 + 4 hours).
However, the timing of administering the next bag depends on when the current bag will run out. Since there is still 500 ml remaining, it will take 4 more hours until the IV solution runs out, which is at 1800.

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A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

Correct Answer is B

Explanation

A nurse is reviewing a client's prescription for 1,000 ml of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 ml of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?

Correct Answer is D

Explanation

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