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 ["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.
Correct Answer is A
Explanation
A. "You must feel frustrated." This response is therapeutic and validates the nurse’s feelings, encouraging the nurse to open up about their frustration without feeling judged or defensive.
B. "Why do you feel upset about this?": Asking “why” may make the nurse defensive and feel as though they need to justify their feelings.
C. "You should be working harder.": This is unsupportive and could worsen the nurse’s frustration, possibly making them feel criticized or undervalued.
D. "I will reprimand your team members.": This response is reactive and could disrupt team dynamics without addressing the underlying issue. It does not support open communication.