A nursing instructor is observing a nursing student auscultating a client’s bowel sounds. Which of the following actions might require the instructor’s intervention?
Performs auscultation between meals
Clamps the Naso Gastric tube during auscultation
Palpates the abdomen prior to performing auscultation.
Auscultates bowel sounds for 3 to 5 min
The Correct Answer is C
A. Performs auscultation between meals:
Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.
B. Clamps the Naso Gastric tube during auscultation
Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.
C. Palpates the abdomen prior to performing auscultation:
Palpating the abdomen before auscultation may interfere with normal bowel sounds
D. Auscultates bowel sounds for 3 to 5 min:
Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assess the pedal pulses with a Doppler device:
Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.
B. Assess the apical pulse with a Doppler device:
While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.
C. Assess the apical pulse for a full minute:
This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.
D. Assess the pedal pulses for a full minute:
While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.
Correct Answer is D
Explanation
A. "Do you want to talk about your health concerns?"
While this question acknowledges the client's option to discuss health concerns, it is somewhat closed-ended and might not prompt the client to share specific details.
B. "Would it help to discuss your feelings about this hospitalization?"
This question addresses the client's feelings about the hospitalization, which is important for emotional well-being, but it might not directly elicit information about the client's primary health issues.
C. "Would you tell me about all of your medical issues?"
This question is somewhat open-ended but might be overwhelming for the client. It is more effective to start with a focused question about the reason for seeking care.
D. "What brought you to the hospital?"
This open-ended question encourages the client to share their primary reason for seeking healthcare and allows for a comprehensive discussion about the client's health concerns. It gives the client an opportunity to express their own perspective and share the relevant information about their medical condition or symptoms.
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