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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.

A. Remove the nasal cannula while the client eats. B. Attach a humidifier bottle to the base of the flow meter. C. Apply petroleum jelly to the nares as needed to soothe mucous membranes. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is B

Explanation

Rationale:

A. Removing the nasal cannula while the client eats can interrupt oxygen therapy.

B. Attaching a humidifier bottle to the base of the flow meter helps to humidify the oxygen, preventing dryness and irritation of the nasal passages, which is appropriate for oxygen flow rates above 4 L/min.

C. Applying petroleum jelly to the nares can pose a fire hazard due to its petroleum base.

D. Securing the oxygen tubing to the bed sheet is not necessary and does not ensure the proper administration of oxygen.

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A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

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