During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

1 minute in the center of the abdomen.

10 minutes in each quadrant.

1 minute in each quadrant.

5 minutes in each quadrant.

None

Answer and Explanation

The Correct Answer is D

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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Correct Answer is D

Explanation

A. Paralysis refers to the loss of muscle function in part of your body.
B. Hemiparesis is weakness on one side of the body.
C. Paraphasia is a language disorder where words get jumbled and sentences don't make sense.
D. Paresthesia is an abnormal sensation like tingling, burning, or numbness in the extremities often associated with nerve-related issues.

A. Capillary refill <5 seconds. B. Radial pulses 2+ with regular rate and rhythm bilaterally. C. Feet pale and cool to the touch. D. Right ankle 1+ edema with no perceptible swelling of the leg.

Correct Answer is B

Explanation

A. A capillary refill of less than 5 seconds is considered normal.
B. Radial pulses 2+ with regular rate and rhythm bilaterally indicate good peripheral circulation.
C. Feet that are pale and cool to the touch could indicate decreased perfusion or vascular compromise.
D. Right ankle 1+ edema may suggest some fluid retention but no perceptible swelling of the leg indicates relatively normal findings in that area.

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During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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