The nurse is assessing a patient's bowel sounds.
The nurse does not hear anything for 30 seconds.
How should the nurse document this finding?

Normoactive bowel sounds.

Hypoactive bowel sounds.

Absent bowel sounds.

Hyperactive bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Normoactive bowel sounds are the typical, intermittent gurgling sounds heard during a bowel assessment, indicating normal peristalsis and intestinal activity. The absence of any sounds for 30 seconds suggests a significant reduction or cessation of this activity, which is not consistent with normoactive findings.

Choice B rationale

Hypoactive bowel sounds are characterized by infrequent and faint gurgling sounds, indicating a decrease in intestinal motility. While a pause of 30 seconds without any sounds might precede hypoactive sounds, the complete absence of sounds for this duration is more indicative of a further reduction in bowel activity than simply hypoactivity.

Choice C rationale

Absent bowel sounds are documented when no bowel sounds are heard after listening in each of the four abdominal quadrants for a specified period, typically ranging from 2 to 5 minutes per quadrant. A 30-second period without any sounds in one area is a significant finding that should be documented as absent in that specific quadrant, warranting further assessment.

Choice D rationale

Hyperactive bowel sounds are loud, high-pitched, and frequent gurgling sounds, often described as "borborygmi" or stomach rumbling. These sounds indicate increased intestinal motility, which is the opposite of the finding of no bowel sounds for 30 seconds.

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Correct Answer is D

Explanation

Choice A rationale

Checking gastric residual volume is essential before administering enteral feedings and medications to assess for delayed gastric emptying, which could increase the risk of aspiration. A high residual volume (typically >500 mL or >250 mL on two consecutive checks) may indicate intolerance to the feeding.

Choice B rationale

Turning the client on their left side after administering enteral feedings and medications is not the recommended position. The right lateral decubitus position is preferred as it promotes gastric emptying by allowing gravity to assist the flow of the feeding into the small intestine.

Choice C rationale

Elevating the head of the bed to a 30-45 degree angle during and for at least 30-60 minutes after enteral feedings significantly reduces the risk of aspiration pneumonia. This position utilizes gravity to help keep the feeding within the stomach and prevent reflux into the esophagus and airway.

Choice D rationale

Leaving the client in their position of comfort while feeding them is incorrect. Maintaining an elevated head of bed position (30-45 degrees) is crucial during and after feeding to prevent aspiration, regardless of the client's perceived comfort. A flat or semi-recumbent position increases the risk of regurgitation and subsequent aspiration into the lungs.

A. Add thickener to fluids. B. Place food on the right side of the client's mouth. C. Serve food at a very hot temperature. D. Instruct the client to tilt her head forward when she swallows.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Adding thickener to fluids helps to increase their viscosity, making them easier to swallow and reducing the risk of aspiration in clients with dysphagia. Dysphagia often results from impaired muscle control in the mouth and throat, and thicker fluids move more slowly, allowing more time for coordination of the swallowing reflex.

Choice B rationale

Placing food on the right side of the client's mouth addresses the left-sided weakness following a stroke. This allows the client to use the stronger, unaffected side of their mouth and throat for better control during chewing and swallowing, minimizing the risk of food pooling on the weaker side and potential aspiration.

Choice C rationale

Serving food at a very hot temperature can impair the client's ability to sense the food in their mouth and can increase the risk of burns, especially with sensory deficits that can occur after a stroke. Warm or room temperature foods are generally recommended for clients with dysphagia to enhance safety and comfort.

Choice D rationale

Instructing the client to tilt her head forward when swallowing helps to close the airway and open the esophagus, facilitating the passage of food and liquids down the throat and reducing the risk of aspiration into the trachea and lungs. This chin-tuck maneuver is a common compensatory strategy for dysphagia. .

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The nurse is assessing a patient's bowel sounds.The nurse does not hear anything for 30 seconds.How should the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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The nurse is assessing a patient's bowel sounds.
The nurse does not hear anything for 30 seconds.
How should the nurse document this finding?