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?

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.

A. Inform the client that an advance directive discontinues further care.This statement is incorrect. An advance directive does not discontinue further care but outlines the client's preferences for medical treatment if they become unable to communicate their wishes.

B. Initiate a power of attorney for health care documents.This is not the nurse's responsibility. Initiating a power of attorney for health care documents typically involves legal consultation, and the client should be referred to appropriate resources.

C. Document that the provider discussed do-not-resuscitate status with the client.This is correct. The nurse should document that the provider has discussed DNR (Do Not Resuscitate) status with the client, ensuring that the discussion and decision are clearly recorded in the medical record.

D. Provide the client with written information about advance directives.This is correct. The nurse is responsible for providing the client with written information about advance directives, ensuring the client understands their rights and options.

E. Communicate advance directives status via the medical record and shift report.This is correct. The nurse must ensure that the client's advance directive status is clearly communicated in the medical record and during shift reports to ensure continuity of care.

F. Instruct the client that an advance directive is a legal document and must be honored by care providers.This is correct. The nurse should inform the client that an advance directive is a legal document that healthcare providers are required to honor, according to the client's wishes.