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.

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Correct Answer is C

Explanation

A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.

B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.

C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.

D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.

A. "The client may be having a cardiac event". B. "The client needs an EKG. Please see her immediately". C. "The client is experiencing chest pain and shortness of breath". D. "The client's admitting diagnosis is stage 2 breast cancer".

Correct Answer is C

Explanation

A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.

B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."

C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.

D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.

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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 caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?

Correct Answer is C

Explanation

A nurse is contacting the provider about a client. Which statement is an example of the S in SBAR?

Correct Answer is C

Explanation

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