a nurse assisting with data collection is preparing to auscultate for bowel sounds the nurse should use which technique
Logo

Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?

Correct answer: A

Rationale: To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment. Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds. Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation. Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.

2. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

3. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

4. A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?

Correct answer: A

Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.

5. A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client?

Correct answer: A

Rationale: The correct answer is that the female condom offers protection against sexually transmitted infections (STIs). Unlike the male condom, the female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. It is used once and then discarded, making choice C incorrect. Female and male condoms should not be used together, so choice B is incorrect. Additionally, no contraceptive method is 100% effective in preventing pregnancy, making choice D incorrect.

Similar Questions

The LPN is caring for a client newly diagnosed with HIV. Which statement made by the client regarding antiretroviral therapy (ART) would require correction from the nurse?
A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?
A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?
A nurse assisting with data collection is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?
A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses