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 ["0.7"]

Explanation

To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:

D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)

In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:

35 mg / 50 mg/mL x 1 mL = 0.7 mL

Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.

A. Place the client on bed rest in supine position. B. Repeat auscultation after asking the client to breathe deeply and cough. C. Prepare to administer antibiotics. D. Instruct the client to limit fluid intake to less than 2,000 mL/day.

Correct Answer is B

Explanation

A. Place the client on bed rest in supine position:

While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.

B. Repeat auscultation after asking the client to breathe deeply and cough:

This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.

C. Prepare to administer antibiotics:

Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.

D. Instruct the client to limit fluid intake to less than 2,000 mL/day:

Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ordered: Hydroxyzine (Vistaril) 35 mg IM stat Available: Hydroxyzine (Vistaril) 50 mg/mL Administer: ____ ml

Correct Answer is ["0.7"]

Explanation

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