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 B
Explanation
Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In general, withholding pain medication for a client in pain is not an appropriate action.
Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration.
It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim. The nurse should perform a thorough pain assessment, including the location, intensity, and quality of the pain, and consider non-pharmacological interventions to help manage the pain.
Correct Answer is B
Explanation
The SBAR (Situation, Background, Assessment, Recommendation) system is a standardized way of communicating critical information between healthcare professionals, particularly during patient handoffs or when escalating a concern.
The recommendation component is where the healthcare professional providing the report suggests a course of action or plan for the patient based on the situation, background, and assessment. For example, a recommendation might be, "I recommend increasing Mr. Smith's pain medication to manage his discomfort," or "I recommend a consult with the nutritionist to address Mrs. Brown's malnutrition."
Of the options provided, (a) provides the situation, (c) provides the assessment, and (d) provides a specific finding from the assessment. Option (b) is a specific recommendation or plan.
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