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The absence of bowel sounds is established after listening for:

A.

2 full minutes.

B.

1 full minute.

C.

5 full mutes.

D.

1 1/2 minutes.

Answer and Explanation

The Correct Answer is C

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

 

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

 

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

 

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.


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View Related questions

Correct Answer is ["A","E","F"]

Explanation

A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.

B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.

C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.

D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.

E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.

F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.

Correct Answer is C

Explanation

A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.

B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.

C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.

D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.

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