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
a. Sounds are high-pitched.
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 in 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 C
Explanation
Sponge baths are recommended until the umbilical cord stump falls off, which typically occurs within the first two weeks of life. After that, the baby can be immersed in water for a regular bath. Using talcum powder is not recommended as it can be harmful to the baby's respiratory system if inhaled. Mild, pH-balanced soap should be used instead of alkaline soap to avoid irritating the baby's delicate skin. The bathwater temperature should be around 98 degrees Fahrenheit and not hoter than 100 degrees Fahrenheit to prevent burns.
Correct Answer is A
Explanation
When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side effects.
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