A nursing instructor is observing a nursing student auscultating a client’s bowel sounds. Which of the following actions might require the instructor’s intervention?

Performs auscultation between meals

Clamps the Naso Gastric tube during auscultation

Palpates the abdomen prior to performing auscultation.

Auscultates bowel sounds for 3 to 5 min

Answer and Explanation

The Correct Answer is C

A. Performs auscultation between meals:

Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.

B. Clamps the Naso Gastric tube during auscultation

Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.

C. Palpates the abdomen prior to performing auscultation:

Palpating the abdomen before auscultation may interfere with normal bowel sounds

D. Auscultates bowel sounds for 3 to 5 min:

Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.

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Correct Answer is A

Explanation

A. The client:

The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.

B. Progress note:

Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.

C. Medical history:

The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.

D. Family information:

Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.

A. Wheezes B. Stridor C. Rhonchi D. Crackles

Correct Answer is D

Explanation

A. Wheezes:

Wheezes are high-pitched, musical sounds that occur during inspiration or expiration and are often associated with narrowed airways, such as in conditions like asthma or chronic obstructive pulmonary disease (COPD).

B. Stridor:

Stridor is a high-pitched, crowing sound that is typically heard during inspiration and can be associated with upper airway obstruction, such as in croup or epiglottitis.

C. Rhonchi:

Rhonchi are low-pitched, snoring or rattling sounds that can occur during inspiration or expiration. They are often associated with the presence of mucus or other airway obstruction and can be heard in conditions like bronchitis or pneumonia.

D. Crackles:

Crackles are bubbling, popping sounds heard during inspiration or expiration. They can be further classified as fine or coarse. Fine crackles are often associated with conditions like pulmonary fibrosis, while coarse crackles can be heard in conditions like congestive heart failure or pneumonia.

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