A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

Sounds are high-pitched

Can be a result of a paralytic ileus

Indicates decreased motility

Sounds are soft and at a rate of 1/min

Answer and Explanation

The Correct Answer is A

Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.

Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.

Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.

Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.

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Correct Answer is B

Explanation

Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. It is caused by increased blood flow and vascular changes in the area. It is considered a normal finding in early pregnancy and is often used as a sign to support the diagnosis of pregnancy.

Ballottement refers to a palpable rebound of the fetus when the examiner pushes on the mother's abdomen.

Hegar's sign is the softening and compressibility of the lower uterine segment, which can be felt during a bimanual examination.

Chloasma refers to the development of hyperpigmented patches on the face, often referred to as the "mask of pregnancy."

A. "I will place the patch on a hairless area of skin." B. "I will remove the patch if I develop a headache." C. "I will replace the patch every 12 hours." D. "I will apply the patch in the same place every day."

Correct Answer is A

Explanation

The client should choose a clean, dry, hairless area of skin to apply the patch. It is important to rotate the application site to avoid skin irritation and ensure consistent drug absorption. The patch should be replaced every 24 hours, not every 12 hours. If the client experiences a headache, it is not necessary to remove the patch, as headaches can be a common side effect of nitroglycerin use. Applying the patch in the same place every day can lead to skin irritation and decreased absorption.

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A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

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