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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.
Correct Answer is C
Explanation
A. The sigmoid is a part of the large intestine located in the left lower quadrant, so tenderness in the right lower quadrant is unlikely to be related to the sigmoid.
B. The liver is situated higher in the abdomen, typically more towards the right upper quadrant, and its tenderness wouldn't manifest in the right lower quadrant.
C. Tenderness in the right lower quadrant is a classic sign of appendicitis, suggesting inflammation of the appendix.
D. The gallbladder is positioned closer to the liver, in the right upper quadrant, and wouldn't typically cause tenderness in the right lower quadrant.
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