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
The nurse will document the patient's chest pains that move down her left arm as radiating pain. Radiating pain is a type of pain that starts at a specific point and spreads outwards to other areas of the body. In this case, the pain starts in the chest and moves down the left arm, which is a common symptom of cardiac or heart-related issues. Phantom pain is a type of pain that is perceived to be present in a body part that has been amputated or lost. Referred pain is pain that is felt in a different part of the body from where the actual problem is located. Somatic pain is pain that arises from the skin, muscles, bones, or connective tissues.
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.
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