Nokea
When assessing bowel sounds, what action should a healthcare professional take?
- A. Listen to the bowel sounds before performing abdominal palpation
- B. Auscultate for 2 minutes to determine if bowel sounds are present
- C. Place the diaphragm of the stethoscope over each quadrant
- D. Ask the client to cough while auscultating
Correct Answer: C
Rationale: When assessing bowel sounds, it is crucial to listen before performing any palpation as palpation can alter bowel sounds. The correct technique involves placing the diaphragm of the stethoscope over each quadrant of the abdomen to listen for bowel sounds. Auscultating for at least 5 minutes is recommended to accurately determine the presence or absence of bowel sounds. Asking the client to cough is not necessary for assessing bowel sounds and may not provide relevant information. Therefore, option C is the correct choice as it follows the appropriate procedure for assessing bowel sounds.
You may also like to solve these questions
The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
- A. Observe the appearance of the skin under the ice pack.
- B. Instruct the client regarding the importance of the covering.
- C. Reapply the covering after filling it with fresh ice.
- D. Ask the client how long the ice pack was applied to the skin.
Correct Answer: A
Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.
When replacing a client's surgical dressing, what should the nurse do?
- A. Don sterile gloves to remove the old dressing
- B. Wash hands thoroughly before removing the old dressing
- C. Use sterile gloves to remove the old dressing
- D. Apply a new dressing before removing the old one
Correct Answer: C
Rationale: When replacing a client's surgical dressing, the nurse should use sterile gloves to remove the old dressing. Sterile technique is essential to prevent introducing infection to the wound. Choice A is incorrect because clean gloves are not sufficient; sterile gloves are necessary to maintain asepsis. Choice B, washing hands, is an important step before and after the procedure to maintain hand hygiene, but sterile gloves are required during the dressing change. Choice D is incorrect because a new dressing should only be applied after the old one has been removed to prevent contamination and ensure proper wound care.
To evaluate a client's understanding of self-administering insulin within the psychomotor domain of learning, what action should the instructor take?
- A. Have the client demonstrate the procedure.
- B. Explain the procedure again.
- C. Ask the client to describe the procedure.
- D. Observe the client watching a video on the procedure.
Correct Answer: A
Rationale: Having the client demonstrate the procedure is the most appropriate action to evaluate understanding within the psychomotor domain of learning. This allows the instructor to assess the client's ability to perform the skill, which is a key aspect of this domain. Choice B, explaining the procedure again, focuses on the cognitive domain rather than the psychomotor domain. Choice C, asking the client to describe the procedure, pertains more to the verbal or cognitive domain of learning. Choice D, observing the client watching a video on the procedure, does not directly assess the client's ability to perform the skill in the psychomotor domain.
The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?
- A. Neck, shoulders, and chest
- B. Abdomen and groin/perineum
- C. Legs, feet, and web spaces
- D. Back of neck, back, and then buttocks
Correct Answer: B
Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.
The client is being taught how to use a peak flow meter. The nurse explains that this device should be used to:
- A. Determine oxygen saturation
- B. Measure forced expiratory volume
- C. Monitor the atmosphere for the presence of allergens
- D. Provide metered doses for inhaled bronchodilator
Correct Answer: B
Rationale: A peak flow meter is used to measure forced expiratory volume, which helps in monitoring asthma. This measurement provides valuable information about how well the client's lungs are functioning and how narrow their airways are. Choice A is incorrect because determining oxygen saturation is typically done using a pulse oximeter. Choice C is incorrect as a peak flow meter is not used to monitor the atmosphere for allergens but rather to assess lung function. Choice D is incorrect as providing metered doses for inhaled bronchodilators is the function of a metered-dose inhaler, not a peak flow meter.