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 ["A","B","D","E"]
Explanation
A. Wearing a mask helps protect against the transmission of airborne particles, which is important for preventing the spread of tuberculosis.
B. Wearing a gown can provide an additional barrier to prevent the transmission of infectious material.
C. Disposing sharps here is not directly related to tuberculosis precautions. This statement is more relevant for a sharps disposal container.
D. Wearing gloves is important to prevent direct contact with potentially contaminated surfaces.
E. Hand hygiene is crucial for infection control and should be emphasized for anyone entering or exiting the room of a client in isolation.
F. "Radiation inside" is not applicable to the isolation precautions for tuberculosis. This statement is unrelated to tuberculosis precautions and may cause confusion.
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.
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