After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Elevate the head of the client's bed immediately.

Use the bell of the stethoscope to auscultate again.

Document the presence of borborygmi.

Auscultate the remaining two quadrants.

Answer and Explanation

The Correct Answer is C

Answer: C. Document the presence of borborygmi.

Rationale:

A. Elevate the head of the client's bed immediately:
While elevating the head of the bed may be appropriate in certain situations, it is not the necessary immediate action in this context. The presence of loud, high-pitched bowel sounds does not indicate a need for repositioning the client. Instead, the nurse should first focus on assessing the findings before making any positional changes.

B. Use the bell of the stethoscope to auscultate again:
The bell of the stethoscope is typically used for lower frequency sounds, such as heart murmurs or certain vascular sounds. Since the nurse has already identified high-pitched bowel sounds using the diaphragm, switching to the bell is not appropriate for this situation. The diaphragm is better suited for detecting the types of sounds the nurse is hearing.

C. Document the presence of borborygmi:
Borborygmi refers to the loud, gurgling bowel sounds that can indicate increased intestinal activity. Documenting this finding is essential as it provides a clear record of the client's bowel sounds at this moment. This documentation can aid in monitoring the client's gastrointestinal function and is crucial for continuity of care.

D. Auscultate the remaining two quadrants:
While it is important to auscultate all quadrants to get a complete assessment of bowel sounds, the immediate action after hearing significant sounds in two quadrants is to document the findings. Continuing the assessment can follow, but the documentation serves as an important step in patient care and communication among the healthcare team.

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Correct Answer is A

Explanation

A) Initiate NPO status: The client's sudden cessation of breathing during deep palpation of the abdomen suggests peritoneal irritation, which could be indicative of a serious condition such as appendicitis or peritonitis. Initiating NPO (nothing by mouth) status is crucial in case emergency surgery is required to address the underlying abdominal pathology. NPO status helps prevent complications such as aspiration if surgery becomes necessary.

B) Restrict activity to bed rest: While bed rest may be indicated for certain abdominal conditions to reduce discomfort and prevent exacerbation of symptoms, it is not the most immediate priority in this scenario. The priority is addressing the potential need for emergency surgery and ensuring the client's safety.

C) Monitor urinary output: Monitoring urinary output is important for assessing hydration status and renal function, but it is not the most critical intervention in this scenario where peritoneal irritation is suspected.

D) Obtain an electrocardiogram: While an electrocardiogram (ECG) may be warranted in certain situations, such as if the client is experiencing chest pain or symptoms suggestive of cardiac involvement, it is not indicated as the most immediate action in this scenario of acute abdominal pain and potential peritoneal irritation.

A. Closed ended questions. B. Leading questions. C. Detailed questions about a symptom. D. Open ended questioning.

Correct Answer is D

Explanation

A) Closed ended questions:
Closed-ended questions typically elicit short, specific responses and may not provide comprehensive information about the sputum's characteristics.

B) Leading questions:
Leading questions suggest a particular answer and may bias the client's response, preventing the nurse from obtaining an accurate description of the sputum.

C) Detailed questions about a symptom:
While detailed questions can be useful, they may be too specific initially and might not allow the client to freely describe their sputum in their own words.

D) Open ended questioning:
Open-ended questions encourage the client to provide more detailed and descriptive responses, allowing the nurse to gather comprehensive information about the sputum's color, consistency, amount, and other characteristics. This technique is best for obtaining a thorough and accurate description of symptoms.

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After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Rationale:

Nursing Test Bank

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Correct Answer is D

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