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 ["A","D","E"]
Explanation
A. Client reports feeling dizzy when sitting up from a supine position.
Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.
B. Client reports feeling palpitations when rising from a supine to a standing position.
Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.
C. Erythema is present on the bilateral lower extremities.
Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.
D. The client has a temperature of 100.4 F.
Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.
E. The client states, “I feel lightheaded when sitting up.”
Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.
Correct Answer is A
Explanation
A. Check temperature and SPO2
When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.
B. Report the rate to the primary care provider:
Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.
C. Check the pulse again in 2 hours:
Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.
D. Record the information:
Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.
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