Patient Data
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

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

Turn the suction off while auscultating

Palpate the abdomen before auscultating

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

Answer and Explanation

Correct Answer : A,C,E

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants. Using a warmed stethoscope bell helps ensure that the stethoscope is at a comfortable temperature for the patient. However, the diaphragm of the stethoscope is typically used for bowel sounds, not the bell. Placing the stethoscope lightly over all four quadrants ensures that you are listening to all areas of the abdomen.

B. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent. This is not necessary for most clinical situations. If bowel sounds are not heard within 1-2 minutes, you may document them as absent. Listening for a full 5 minutes is typically reserved for more specific assessments, such as suspected bowel obstruction.

C. Turn the suction off while auscultating. Suction from a nasogastric tube can cause noise that may interfere with the assessment of bowel sounds. Turning off the suction ensures that you can hear the actual bowel sounds without interference.

D. Palpate the abdomen before auscultating. Palpation should be done after auscultation to avoid stimulating bowel sounds, which can affect the accuracy of your assessment. Palpating before auscultation may alter the natural bowel sounds and provide misleading results.

E. Place the stethoscope in the ears with the earpieces pointing towards the ears. The earpieces of the stethoscope should point towards the ears to ensure proper acoustics and clear sound transmission.

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Correct Answer is C

Explanation

A. Offer to administer a laxative prescribed for PRN use. Laxatives are not appropriate for managing rebound tenderness, which can indicate peritonitis or other serious conditions.

B. Obtain a prescription to catheterize the client's bladder. Catheterization is not related to managing rebound tenderness.

C. Notify the healthcare provider of the rebound tenderness. This is the best choice as rebound tenderness can indicate peritonitis or another acute abdominal condition requiring immediate medical attention.

D. Instruct the client in distraction and relaxation techniques. While useful for pain management, this does not address the underlying serious condition indicated by rebound tenderness.

A. Impaired memory. B. Impaired concentration. C. Impaired thinking. D. Normal mental status for age.

Correct Answer is C

Explanation

A. Impaired memory.This assesses recall rather than interpretation of abstract concepts.

B. Impaired concentration. This assesses the ability to maintain attention, not abstract reasoning.

C. Impaired thinking. This is the best choice as misinterpreting a proverb indicates difficulty with abstract thinking.

D. Normal mental status for age. Misinterpreting a common proverb indicates a cognitive issue, not a normal mental status.

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Patient Data 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 C

Explanation

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Patient Data
Exhibits

The nurse is assessing the client for bowel sounds.

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