A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

Hypoactivity

Paralytic ileus

Borborygmi

Distention

Answer and Explanation

The Correct Answer is C

A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

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Correct Answer is C

Explanation

A. Wheelchair is on the left side, which is the postoperative knee, risking strain or injury to the healing limb during transfer. Not ideal for maximizing client safety and independence in mobility.

B: Wheelchair is placed at the head of the bed, making it impractical and unsafe for transfer. No clear pivot point, and body mechanics would be compromised for both the nurse and the client.

C. The wheelchair is positioned on the client's right side, which is the unaffected leg, allowing the client to pivot and transfer using their stronger limb. This placement minimizes strain on the left surgical knee, which reduces pain and risk of injury.

A. Remove blankets from the client. B. Place cold packs on the client's axillae. C. Place a fan to blow air across the client. D. Give the client an alcohol sponge bath.

Correct Answer is A

Explanation

A. Removing blankets from the client helps reduce external heat sources and allows body heat to dissipate, which can aid in lowering the elevated temperature. This action supports the body’s natural cooling mechanisms and provides comfort during a febrile state.

B. Placing cold packs on the axillae can help lower body temperature by cooling major blood vessels near the skin’s surface. However, this method may cause discomfort or shivering, which can paradoxically increase metabolic heat production and is less preferred than removing excess coverings.

C. Using a fan to blow air across the client promotes evaporative cooling, but if the client is shivering or chills are present, this can increase discomfort and cause the body to generate more heat. Fans are best used when the client is comfortable and not experiencing chills.

D. Giving an alcohol sponge bath is generally discouraged because alcohol is rapidly absorbed through the skin and can cause toxicity. Additionally, it can cause vasodilation, which might lead to increased heat loss and potential hypothermia if not carefully monitored.

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