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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Correct Answer is B

Explanation

A. Metabolic alkalosis is characterized by an elevated HCO3 and pH.
B. Metabolic acidosis is indicated by a low HCO3 (18 mEq/L) and a low pH (7.30). The low PaCO2 is a compensatory response.
C. Respiratory acidosis is indicated by an elevated PaCO2 and a low pH.
D. Respiratory alkalosis is indicated by a low PaCO2 and an elevated pH.

A. Hiccups B. Heartburn C. Orthostatic hypotension D. Diarrhea

Correct Answer is C

Explanation

A. Hiccups are not a common adverse effect of morphine.
B. Heartburn is not a common adverse effect of morphine.
C. Orthostatic hypotension is a known adverse effect of morphine due to its potential to cause vasodilation and lower blood pressure, especially when the client changes positions.
D. Diarrhea is not a common adverse effect of morphine; constipation is more likely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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