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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
A. Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B. Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C. When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D. Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.
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