The absence of bowel sounds is established after listening for:
2 full minutes.
1 full minute.
5 full mutes.
1 1/2 minutes.
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
Explanation
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.
Correct Answer is ["B","C","D","E"]
Explanation
A. Cleanses the ear molds with isopropyl alcohol to remove cerumen: Alcohol is not recommended for cleaning hearing aids, as it can damage the device. A mild soap and water solution or a designated cleaning tool is preferable.
B. Turns off the hearing aids when not in use: Turning off hearing aids conserves battery life, which is a proper maintenance practice.
C. Inspects the ear molds to determine the ear canal portion: Properly positioning the hearing aids ensures correct use and comfort.
D. Turns the volume all the way down before inserting the hearing aids: This prevents a sudden loud noise that could startle the client and allows them to adjust to a comfortable volume after insertion.
E. Ensures that the ears are not blocked with cerumen: Blocked cerumen can interfere with hearing aid functionality, so this is an essential step.