The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

Listen for another minute just to be sure

Contact the physician as this is a surgical emergency.

Auscultate for another 4 minutes

Listen posteriorly for enhanced bowel sounds

Answer and Explanation

The Correct Answer is C

A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.

B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.

C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.

D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Information sharing is limited to those directly involved in the client's care: This statement reflects the principle of confidentiality and the ethical obligation to protect the client's private health information. Only healthcare providers directly involved in the client’s care should have access to their information, ensuring that it remains secure and confidential.

B) All members of the unit's healthcare team may have access to the client's chart: While many healthcare team members need access to the client's information for care coordination, this statement is misleading. Access should be limited to those directly involved in the client’s care to protect their confidentiality.

C) The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client: While HIPAA does set guidelines for the protection of health information and governs the sharing of health data, it does not specifically determine who may communicate with the client. Instead, it focuses on protecting their privacy.

D) The medical records are open to any hospital employee, including administration: This statement is incorrect as it violates confidentiality principles. Medical records are not accessible to all hospital employees; access is restricted to authorized personnel only, ensuring that patient information is kept confidential.

A. Lordosis B. Scoliosis C. Kyphosis D. Normal curve

Correct Answer is A

Explanation

A) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.

B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.

C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.

D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the acute care unit. Which should the nurse consider when regarding the confidentiality of the client?

Correct Answer is A

Explanation

The nurse notes an exaggerated cervical curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record?

Correct Answer is A

Explanation

A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?

The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?

When assessing the skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?

A resident in an assisted-living facility is restless most nights and sits in the lounge area reading. When questioned, the resident reports suffering from insomnia. What should the nurse expect as an outcome if the resident continues with this pattern of sleep?

When conducting a peripheral vascular assessment on the upper extremities of a client, the nurse should include which assessments? Select all that apply

A student nurse documents the following: Lower left leg cool, mild edema, with dorsalis pedis, posterior knee and femoral pulse normal. How should this documentation be charted to communicate the assessment using appropriate medical terminology?

Based on an understanding of the cognitive changes that normally occur with aging. what would the nurse expect a newly hospitalized older adult to do?

The nurse is preparing to assess the motor function of the client's trigeminal nerve. Which of the following tests would be most appropriate for the nurse to use?