A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

High-pitched, tinkling sounds

Normal bowel sound

Hypoactive bowel sounds

Hyperactive bowel sounds

Answer and Explanation

The Correct Answer is C

A. High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.

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Correct Answer is B

Explanation

A. Pretibial edema: Edema is more indicative of venous function, not arterial function.

B. Palpate pedal pulses bilaterally: Palpation of the pedal pulses is essential to assess arterial circulation in the lower extremities.

C. Allen test: This assesses arterial blood flow to the hand, not the lower extremities.

D. Homan sign: Homan sign is used (though controversial) to assess for deep vein thrombosis (DVT), which is related to venous, not arterial, function.

A. Consider this a normal capillary refill time that requires no further assessment. B. Consider this a delayed capillary refill time, and investigate further. C. Ask the patient about a history of frostbite. D. Suspect that the patient has venous insufficiency.

Correct Answer is B

Explanation

A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.

B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.

C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.

D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.

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A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following should the nurse perform to assess the arterial function of the lower extremities?

Correct Answer is B

Explanation

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Correct Answer is B

Explanation

When assessing the abdomen most health care providers divide the abdomen into how many sections?

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

The nurse is testing a patient's visual accommodation, which refers to which action?

Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply)