The nurse auscultates the client’s abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?
Auscultate for another 4 minutes.
Listen for another minute just to be sure.
Contact the physician as this is a surgical emergency.
Listen posteriorly for enhanced bowel sounds.
The Correct Answer is B
The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be affected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The CAGE acronym is a brief screening tool used to assess alcohol misuse or dependence. It consists
of four questions that can be easily remembered using the acronym CAGE:
C - Have you ever felt you needed to Cut down on your drinking?
A - Have you ever felt Annoyed by criticism of your drinking? G - Have you ever felt Guilty about your drinking?
E - Have you ever felt the need for an Eye-opener (drink) in the morning?
Correct Answer is B
Explanation
The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be affected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.
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