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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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Correct Answer is ["A","C","D"]

Explanation

A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.

B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.

C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.

D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.

E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.

Correct Answer is C

Explanation

A. 20: Incorrect, as it would imply a much higher dose.

B. 0.2: Incorrect, as this would be far too low.

C. 2: Phenytoin 0.2 g is equivalent to 200 mg (0.2 g x 1000 mg/g). Since each capsule is 100 mg, the nurse would need to administer 2 capsules (200 mg / 100 mg per capsule = 2).

D. 200: Incorrect, as 200 capsules would be an overdose.

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