The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?
Perform abdominal percussion, and then repeat auscultation.
Palpate the client's abdomen to stimulate bowel motility.
Repeat auscultation in four to six hours.
Listen for five minutes before documenting an absence of bowel sounds.
The Correct Answer is D
A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.
B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.
C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.
D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. S3: This sound is associated with early diastole, often related to heart failure or volume overload.
B. S1: The first heart sound (S1) marks the beginning of systole and corresponds to the closure of the mitral and tricuspid valves.
C. S2: The second heart sound (S2) indicates the end of systole and the beginning of diastole, associated with the closure of the aortic and pulmonic valves.
D. S4: This sound is associated with late diastole, often related to decreased ventricular compliance.
Correct Answer is A
Explanation
A. Posterior tibial: The posterior tibial pulse is palpated just behind the medial malleolus of the ankle, near the Achilles tendon.
B. Femoral: The femoral pulse is located in the groin area, where the femoral artery passes.
C. Popliteal: The popliteal pulse is palpated behind the knee in the popliteal fossa.
D. Dorsalis pedis: The dorsalis pedis pulse is located on the top of the foot, near the first metatarsal.
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