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
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Correct Answer is A
Explanation
A. This statement indicates a need for further teaching as a high fiber diet is not directly related to reducing the risk of skin cancer.
B. Avoiding tanning booths is appropriate advice for preventing skin cancer due to the high exposure to UV radiation.
C. Using sunscreen on cloudy days is good advice as UV rays can penetrate through clouds and still cause skin damage.
D. Regularly checking the skin for changes is important for early detection of skin cancer and is appropriate advice.
Correct Answer is ["2"]
Explanation
To administer the correct dose of penicillin G benzathine, which is 1.2 million units, and given that the available concentration is 600,000 units per mL, the nurse should calculate the volume to administer based on these values. By dividing the prescribed dose by the concentration available, the nurse can determine the volume needed for injection. In this case, 1.2 million units divided by 600,000 units per mL results in 2 mL.
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