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. Diaphragm on one side, bell on the opposite side: Suitable for a full cardiac examination, as it can assess both high and low-frequency sounds.
B. Diaphragm Only: Less suitable for a full cardiac examination because it may not effectively capture low-frequency sounds such as certain heart murmurs.
C. Bell on one side, Diaphragm on the opposite side: Effective for a full cardiac examination, as it can assess both high and low-frequency sounds.
D. Diaphragm and bell on same side: Allows for a complete assessment of heart sounds, though it may be less versatile than separate components on each side.
Correct Answer is D
Explanation
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
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