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 D

Explanation

A. Vesicular breath sounds are normal lung sounds heard over most of the lung fields, including the bases. Therefore, they do not need to be reported as abnormal.
B. There is no indication that coughing is needed since the breath sounds are normal.
C. Measuring oxygen saturation is not necessary at this moment, as the vesicular sounds are a normal finding.
D. Vesicular sounds are expected, normal breath sounds in the lung bases. The nurse should continue with the remainder of the physical assessment.

A. Give the client 8 ounces (236.5 mL) of water to drink. B. Evaluate the client for bladder distention. C. Instruct the client to attempt to urinate again. D. Send the sample for laboratory evaluation.

Correct Answer is B

Explanation

A. Giving the client water to drink might help produce more urine, but it does not address the immediate issue of potential bladder distention, which can cause discomfort and urinary retention.
B. Evaluating the client for bladder distention is the priority action. The symptoms of lower abdominal discomfort and difficulty urinating suggest possible urinary retention, which could be due to an enlarged prostate or other obstructive issues. Assessing for bladder distention will help determine if the bladder is full and if further interventions, such as catheterization, are needed.
C. Instructing the client to try urinating again may not be effective if the client is experiencing urinary retention, and it doesn't address the underlying issue.
D. Sending the few drops of urine for evaluation could provide some information but does not address the potential problem of bladder distention or retention.

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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

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is D

Explanation

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is B

Explanation

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

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When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Exhibits

The nurse is assessing the client for bowel sounds.

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