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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
After a transurethral resection of the prostate (TURP), it is expected for the client to have some blood in the urine. Initially, the urine may be bright red or pink due to the surgical procedure's trauma to the prostate and surrounding tissues. However, as time passes, the urine should gradually become lighter in color.
If the client's urine remains dark red, it may indicate active bleeding or a significant amount of blood in the urine, which could be a cause for concern.
Correct Answer is A
Explanation
Hepatitis A is primarily transmitted through the fecal-oral route, often due to contaminated food or water. However, it can also spread through close personal contact, including sharing towels, utensils, or other personal items. By using different hand towels than others in the home, the client demonstrates an understanding of the importance of preventing the transmission of the virus.
While hand hygiene is essential in preventing the spread of infectious diseases, including hepatitis A, alcohol-based cleansers are not effective against the hepatitis A virus. Washing hands with soap and water for at least 20 seconds is the recommended method to remove the virus from the hands.
Hepatitis A can be spread through contaminated food, so it is important for the client to avoid preparing food for others during the acute phase of the illness and until cleared by a healthcare professional.
Hepatitis A is not typically transmitted through contact with blood. It is primarily transmitted through the fecal-oral route or close personal contact with an infected individual.
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