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 B

Explanation

A. Snoring and bilateral, pale gray nodules. This suggests the presence of nasal polyps, which can be associated with chronic allergic conditions but not specific to allergic rhinitis.

B. Intranasal edema and swelling of turbinates. This is the best choice as it directly describes physical signs commonly seen in allergic rhinitis, indicating inflammation and swelling due to allergen exposure.

C. Purulent secretions from eyes and nares. This suggests an infection rather than an allergic reaction. Allergic rhinitis typically causes clear, watery secretions.

D. Eye tearing and thick yellow nasal drainage. Thick yellow nasal drainage is more indicative of a bacterial infection rather than allergic rhinitis, which causes clear secretions.

A. Retracted and non-mobile tympanic membrane. B. Translucent, pearly gray and mobile tympanic membrane. C. Red, edematous ear canal with no visualization of the tympanic membrane. D. Thickened and bulging tympanic membrane.

Correct Answer is C

Explanation

A. Retracted and non-mobile tympanic membrane. This finding is more typical of eustachian tube dysfunction or middle ear effusion, not an external ear infection.

B. Translucent, pearly gray and mobile tympanic membrane. This is a normal finding, which is unlikely given the symptoms described.

C. Red, edematous ear canal with no visualization of the tympanic membrane. This is the expected finding for otitis externa (swimmer's ear), which matches the client's symptoms and history.

D. Thickened and bulging tympanic membrane. This finding is more indicative of middle ear infection (otitis media), not an external ear infection.

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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

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?

Correct Answer is B

Explanation

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

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.