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

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.

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Correct Answer is D

Explanation

Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.

Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.

Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.

Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.

A. Verify the medication three times with the medication administration record. B. Document medication administration prior to administering medication. C. Administer time-critical medication 60 min before or after the scheduled time. D. Identify the client by using one identifier before giving the medication.

Correct Answer is A

Explanation

When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.

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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?

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Correct Answer is A

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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?