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 C
Explanation
Choice A rationale
Regulating nerve cell transmission is primarily a function of electrolytes like sodium, potassium, and calcium, as well as neurotransmitters. While fats are components of nerve cell membranes, they do not directly regulate the transmission of nerve impulses.
Choice B rationale
Converting to sugar (glucose) to provide energy is the primary function of carbohydrates. While fats can be metabolized for energy, they are broken down into fatty acids and glycerol, not directly into glucose. Gluconeogenesis can convert glycerol to glucose, but this is a secondary energy pathway.
Choice C rationale
Fats are crucial for the absorption of fat-soluble vitamins (A, D, E, and K). These vitamins are lipophilic, meaning they dissolve in fats. Dietary fat is necessary in the small intestine to emulsify these vitamins, allowing them to be absorbed across the intestinal lining into the bloodstream.
Choice D rationale
Building and repairing tissue is the primary function of proteins, which are composed of amino acids. While fats are components of cell membranes and contribute to overall cell structure, they do not play the main role in tissue synthesis and repair.
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