Nokea
A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds?
- A. Normal
- B. Hypoactive
- C. Hyperactive
- D. Paralytic ileus
Correct Answer: B
Rationale: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.
You may also like to solve these questions
A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production?
- A. Muscle wasting
- B. Chronic jaundice in the absence of liver disease
- C. The presence of fat in the patient's stool
- D. Persistently low hemoglobin and hematocrit
Correct Answer: D
Rationale: In the absence of intrinsic factor, vitamin B12 cannot be absorbed, and pernicious anemia results. This would result in a marked reduction in hemoglobin and hematocrit.
The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test?
- A. In a knee-chest position (lithotomy position)
- B. Lying prone with legs drawn toward the chest
- C. Lying on the left side with legs drawn toward the chest
- D. In a prone position with two pillows elevating the buttocks
Correct Answer: C
Rationale: For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A knee-chest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization.
A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?
- A. Your appendix doesn't play a major role, so you won't notice any difference after you recovery from surgery.
- B. The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate.
- C. Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this.
- D. Your large intestine will adapt over time to the absence of your appendix.
Correct Answer: A
Rationale: The appendix is an appendage of the cecum (not the large intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption.
A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect?
- A. The patient's BUN and creatinine levels are within reference range following the CT.
- B. The CT yields high-quality images.
- C. The patient's electrolytes are stable in the 48 hours following the CT.
- D. The patient's intake and output are in balance on the day after the CT.
Correct Answer: A
Rationale: Both sodium bicarbonate and Mucomyst are free radical scavengers that sequester the contrast byproducts that are destructive to renal cells. Kidney damage would be evident by increased BUN and creatinine levels. These medications are unrelated to electrolyte or fluid balance and they play no role in the results of the CT.
A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of?
- A. Diet high in red meat
- B. Upper GI bleed
- C. Hemorrhoids
- D. Use of iron supplements
Correct Answer: C
Rationale: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.