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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1610"]
Explanation
Step 1: Convert ounces to milliliters for oral intake. 8 ounces of coffee × 30 mL/ounce = 240 mL. 3 ounces of juice × 30 mL/ounce = 90 mL. 12 ounces of soda × 30 mL/ounce = 360 mL.
Step 2: Calculate the amount of water consumed from the pitcher. Initial amount - Remaining amount = Consumed amount. 800 mL - 200 mL = 600 mL.
Step 3: Calculate the total oral fluid intake. Coffee + Juice + Soda + Water = Total oral intake. 240 mL + 90 mL + 360 mL + 600 mL = 1290 mL.
Step 4: Calculate the total IV fluid intake over 8 hours. IV rate × Time = Total IV fluid. 40 mL/hour × 8 hours = 320 mL.
Step 5: Calculate the total fluid intake (oral + IV). Total oral intake + Total IV fluid = Total intake. 1290 mL + 320 mL = 1610 mL.
The nurse should document 1610 mL as the client's total intake for the shift.
Correct Answer is A,B,C,D
Explanation
Choice A rationale
Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.
Choice B rationale
Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.
Choice C rationale
Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.
Choice D rationale
Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.
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