A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
Auscultates bowel sounds for 3 to 5 min
Clamps the NG tube during auscultation
Performs auscultation between meals
Palpates the abdomen prior to performing auscultation.
The Correct Answer is D
Rationale:
A. Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamping the NG tube prevents false bowel sounds from the tube.
C. Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Sleeping on a firm mattress is generally recommended to support the spine and prevent back strain.
B. Avoiding prolonged sitting helps reduce pressure on the lower back and can prevent back pain.
C. Applying heat intermittently can provide temporary relief but does not prevent back strain.
D. Sleeping in a side-lying position with knees flexed helps maintain natural spinal curvature and reduces strain on the back.
E. Padded shoe insoles may provide comfort. Proper arch support can improve posture and reduce stress on the lower back.
Correct Answer is D
Explanation
A. Providing written materials with large print helps accommodate low literacy levels by enhancing readability and comprehension, but assessing the client’s ability to demonstrate the skill is more crucial to assess understanding.
B. Long teaching sessions can overwhelm clients with low literacy levels and may not improve understanding.
C. Using acronyms may confuse clients with low literacy levels if they are not familiar with medical abbreviations.
D. Asking the client to demonstrate the skill is important, since it allows the nurse to assess the client's comprehension and correct any mistakes during the learning process.
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