When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Absent

Blowing sound due to restriction.

A continuous medium pitched sound.

High pitched, tinkling, rushing or growling.

Answer and Explanation

The Correct Answer is D

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

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Correct Answer is B

Explanation

A. Amber color. Normal urine color ranges from pale yellow to deep amber, depending on hydration. Amber urine alone is not abnormal.

B. White blood cells (WBC) 10. Normal WBC levels in urine should be ≤5 per high-power field (HPF). A count of 10 WBCs suggests infection or inflammation, such as a urinary tract infection (UTI).

C. pH 5.0. Normal urine pH ranges from 4.5 to 8.0, so a pH of 5.0 is within normal limits and does not require reporting.

D. Occasional casts. Occasional hyaline casts are normal, especially with dehydration or vigorous exercise. However, cellular casts (e.g., red blood cell casts) could indicate kidney disease.

A. 4+ B. 3+ C. 2+ D. 1+

Correct Answer is B

Explanation

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory findings for a client who had a urinalysis. Which finding should the nurse report to the provider?

Correct Answer is B

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A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Correct Answer is B

Explanation

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