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 D
Explanation
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.
Correct Answer is C
Explanation
A. Plantarflexion and dorsiflexion refer to movements of the foot and are unrelated to the Phalen test.
B. Hyperextension of the wrists with the palmar surfaces touching is not the correct maneuver for the Phalen test.
C. The Phalen test involves holding both hands back to back while flexing the wrists at a 90- degree angle for about 60 seconds, which may induce symptoms of carpal tunnel syndrome in those affected.
D. Hyperextending the wrists with the palms together doesn’t simulate the stress on the median nerve in the same way as the Phalen test.
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