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 D
Explanation
Choice A rationale
Checking gastric residual volume is essential before administering enteral feedings and medications to assess for delayed gastric emptying, which could increase the risk of aspiration. A high residual volume (typically >500 mL or >250 mL on two consecutive checks) may indicate intolerance to the feeding.
Choice B rationale
Turning the client on their left side after administering enteral feedings and medications is not the recommended position. The right lateral decubitus position is preferred as it promotes gastric emptying by allowing gravity to assist the flow of the feeding into the small intestine.
Choice C rationale
Elevating the head of the bed to a 30-45 degree angle during and for at least 30-60 minutes after enteral feedings significantly reduces the risk of aspiration pneumonia. This position utilizes gravity to help keep the feeding within the stomach and prevent reflux into the esophagus and airway.
Choice D rationale
Leaving the client in their position of comfort while feeding them is incorrect. Maintaining an elevated head of bed position (30-45 degrees) is crucial during and after feeding to prevent aspiration, regardless of the client's perceived comfort. A flat or semi-recumbent position increases the risk of regurgitation and subsequent aspiration into the lungs.
Correct Answer is A
Explanation
Choice A rationale
Carbohydrates are the body's primary source of energy. They are broken down into glucose, which cells use for fuel to perform various functions, including muscle contraction, nerve impulse transmission, and maintaining body temperature.
Choice B rationale
Electrolytes, such as sodium, potassium, and chloride, are minerals that carry an electrical charge and are crucial for fluid balance, nerve function, and muscle contraction. While some foods containing carbohydrates may also contain electrolytes, providing energy is not their primary function. Normal ranges for serum sodium are 135-145 mEq/L, potassium is 3.5-5.0 mEq/L, and chloride is 95-105 mEq/L.
Choice C rationale
Minerals are inorganic substances that the body needs for various functions, including building strong bones, transmitting nerve impulses, and maintaining fluid balance. Examples include calcium, iron, and zinc. While essential, they are not primarily known for providing direct energy. Normal ranges for serum calcium are 8.5-10.5 mg/dL, iron varies by gender (males: 65-175 mcg/dL, females: 50-170 mcg/dL), and zinc is 70-120 mcg/dL.
Choice D rationale
Vitamins are organic compounds that the body needs in small amounts for various metabolic processes. They do not directly provide energy but help the body utilize energy from carbohydrates, fats, and proteins. Examples include vitamin C, vitamin D, and B vitamins. Normal ranges vary widely depending on the specific vitamin.
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