A nurse is checking a client's bowel sounds.
At which of the following times should the nurse auscultate the client's abdomen?
Prior to inspecting the abdomen.
After palpating the abdomen.
After checking for kidney tenderness.
Prior to percussing the abdomen.
The Correct Answer is A
Choice A rationale
Auscultation of the abdomen for bowel sounds should be performed prior to any manipulation such as inspection, palpation, or percussion. Palpation and percussion can stimulate or inhibit bowel motility, potentially altering the sounds heard and leading to an inaccurate assessment of baseline bowel activity.
Choice B rationale
Palpating the abdomen involves applying pressure, which can stimulate bowel motility and increase bowel sounds. Auscultating after palpation might not reflect the client's true baseline bowel sounds.
Choice C rationale
Checking for kidney tenderness involves percussing the costovertebral angle, which is located on the back and does not directly impact bowel sounds. However, it is still a form of manipulation that should ideally occur after auscultation of the abdomen to avoid any potential influence on bowel sounds.
Choice D rationale
Percussion of the abdomen involves tapping the abdominal surface to assess underlying structures. This manipulation can also alter bowel motility and the characteristics of bowel sounds. Therefore, auscultation should precede percussion for an accurate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Dried beans, such as lentils, kidney beans, and chickpeas, are excellent sources of plant-based protein. They contain a significant amount of amino acids, which are the building blocks of protein, making them a valuable addition to a vegetarian toddler's diet to support growth and development.
Choice B rationale
Cooked carrots are primarily a source of vitamins, particularly beta-carotene (a precursor to vitamin A), and fiber. They contain minimal amounts of protein and are not the best choice for increasing dietary protein intake in a vegetarian toddler.
Choice C rationale
Sliced bananas are a good source of carbohydrates, potassium, and some vitamins. However, they are low in protein and would not significantly contribute to increasing the dietary protein intake of a vegetarian toddler.
Choice D rationale
Whole wheat bread contains some protein, but it is not as concentrated a source as dried beans. While whole grains are important for fiber and overall nutrition, dried beans offer a higher protein content per serving, making them a better choice for increasing protein intake.
Correct Answer is A
Explanation
Choice A rationale
Abrupt cessation of total parenteral nutrition (TPN) can lead to a rapid decrease in blood glucose levels. While receiving TPN, the body is continuously supplied with glucose. When this external glucose source is suddenly removed, the pancreas may continue to secrete insulin at a rate higher than needed, resulting in hypoglycemia. Signs and symptoms of hypoglycemia include sweating, tremors, confusion, and dizziness.
Choice B rationale
Hyperthermia, or elevated body temperature above the normal range of approximately 36.5°C to 37.5°C (97.7°F to 99.5°F), is not a typical complication following the discontinuation of TPN. Fever is usually associated with infection or inflammation, neither of which are a direct consequence of stopping TPN.
Choice C rationale
Flatulence, or the accumulation of gas in the digestive tract leading to bloating and the passage of gas, is related to dietary intake and digestive processes. Discontinuing TPN, which bypasses the digestive system, would not directly cause an increase in flatulence. In fact, digestive issues might improve once oral or enteral feeding resumes.
Choice D rationale
Tachycardia, an abnormally rapid heart rate (typically defined as above 100 beats per minute in adults), is not a direct physiological consequence of discontinuing TPN. While changes in fluid balance or electrolyte levels (which can occur with TPN but are monitored closely) could indirectly affect heart rate, hypoglycemia is a more immediate and direct risk upon TPN cessation.
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