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 C

Explanation

A. Performing a mental status exam is important but may not be the immediate priority if the issue could be related to a more straightforward problem such as hearing loss.
B. Orienting the client to her surroundings is helpful but may not address the immediate concern of her ignoring questions, which could be due to hearing issues.
C. Standing directly in front of the client and asking about hearing loss addresses a possible issue with communication immediately. It is crucial to rule out hearing impairment before assuming other causes for the client's behavior.
D. Using a tuning fork to complete Rinne and Weber tests is a valid assessment for hearing loss but is a more specific test that may be implemented after the nurse initially assesses whether hearing loss is a potential issue.

A. Place the dorsum of the hand on the client's forehead. B. Lightly pinch a fold of skin over the client's sternum. C. Ask the client to describe any other related symptoms. D. Use both hands to hold and palpate the client's hands.

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.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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.