A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?
Sounds are high-pitched
Can be a result of a paralytic ileus
Indicates decreased motility
Sounds are soft and at a rate of 1/min
The Correct Answer is A
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.
Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.
Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.
Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.
Correct Answer is B
Explanation
This is done by aspirating a small amount of stomach contents and testing the pH using pH paper or a pH indicator strip. The pH of stomach contents is typically acidic (pH less than 5), indicating proper placement in the stomach.
Injecting air and listening for bubbling is not a reliable method to verify tube placement, as it can lead to complications such as pneumothorax.
Measuring gastric residual is done to assess the amount of gastric contents remaining in the stomach, but it does not confirm tube placement.
Adding food coloring to the formula is not a standard practice and does not provide reliable confirmation of tube placement.
X-ray is the gold standard method to confirm tube placement but is not typically done before every intermittent feeding unless there are concerns about tube placement
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