Exhibits

The nurse is assessing the client for bowel sounds.

Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Use a warmed bell of the stethoscope and place it lightly over the four quads

Place the stethoscope in the ears with the earpieces pointing towards the ears

Tum the suction off while auscultating

Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent

Palpate the abdomen before auscultating

Answer and Explanation

Correct Answer : A,C,D

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

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Correct Answer is A

Explanation

A. Placing the dorsum (back) of the hand on the client’s forehead is a quick method to assess whether the client feels warm to the touch, which can be an indication of fever. Although not as accurate as taking the temperature, this action is a common preliminary step to confirm the suspicion of fever.
B. Lightly pinching a fold of skin over the sternum is a technique used to assess skin turgor and hydration status, not fever. It does not provide information about the client's body temperature.
C. Asking the client to describe related symptoms may help gather subjective data but does not objectively confirm the presence of fever. Direct temperature measurement or physical assessment is necessary for objective confirmation.
D. Using both hands to hold and palpate the client’s hands may provide information about circulation or warmth, but it is not a reliable method to confirm fever. The forehead is a more appropriate location to assess for elevated temperature.

A. Number of blood clots expelled with each stool. B. Unique odor noted with gastrointestinal bleeding. C. Evidence of internal hemorrhoids. D. Color characteristics of each stool.

Correct Answer is D

Explanation

A. While the presence of blood clots in the stool is important, documenting the exact number of clots may not provide as much useful information as other characteristics of the bleeding.
B. A unique odor associated with gastrointestinal bleeding can occur, particularly with melena, but it is not as critical to document as the appearance and characteristics of the stool itself.
C. Evidence of internal hemorrhoids is relevant but does not fully assess the nature and severity of the rectal bleeding.
D. The color characteristics of each stool are crucial in assessing rectal bleeding, as they can provide information about the source of the bleeding (e.g., bright red blood indicating lower GI bleeding or black, tarry stools indicating upper GI bleeding). Documenting stool color helps guide further diagnostic and therapeutic interventions.

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Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Correct Answer is A

Explanation

When evaluating a client's rectal bleeding, which findings should the nurse document?

Correct Answer is D

Explanation

Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m². Based on this BMI, what should the nurse deduce about this client's general health?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Exhibits

The nurse is assessing the client for bowel sounds.

Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.