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?

A. Documentation is a communication tool for the interprofessional health care team

The purpose of documentation in the electronic health record (EHR) includes serving as a communication tool among members of the interprofessional healthcare team. Accurate and timely documentation allows healthcare providers to share information about the client's care, treatment, and outcomes.

B. Documentation allows providers to monitor the nurse’s activities:

While documentation provides a record of the nurse's activities, the primary purpose is to communicate information about patient care rather than serving as a tool for monitoring the nurse's activities.

C. Documentation provides information to the client about financial charges:

The primary purpose of documentation is to record and communicate information about the client's health status, care, and outcomes. Financial information is typically managed separately from clinical documentation.

D. Documentation provides information for a client audit:

While documentation can be used in audits for quality assurance, the primary purpose is to record and communicate information about patient care. The use of documentation for audits is a secondary function related to quality improvement and regulatory compliance.

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.