A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

After palpating the abdomen

Prior to percussing the abdomen

Prior to inspecting the abdomen

After assessing for kidney tenderness

Answer and Explanation

The Correct Answer is B

A.   After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B.   Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C.   Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D.   After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

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Correct Answer is D

Explanation

A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.

B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.

C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.

D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.

A. Irrigate the wound with an antiseptic prior to obtaining the specimen. B. Include intact skin at the wound edges in the culture. C. Swab an area of skin away from the wound to identify the usual flora. D. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

Correct Answer is D

Explanation

A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.

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A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

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Naxlex Comprehensive Predictor Exams

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