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.

Answer and Explanation

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

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Correct Answer is D

Explanation

A. Dependent edema is characterized by swelling in the lower extremities due to gravity and may not always present with pigmentation changes.

B. Stasis ulceration involves ulcerative lesions typically occurring on the lower legs, often associated with venous insufficiency, but the pigmentation alone does not confirm ulceration.

C. Arterial occlusion typically presents with symptoms such as pain, pallor, and decreased pulses, not necessarily with warm skin and brown pigmentation.

D. Venous insufficiency is characterized by symptoms such as warm skin, brown pigmentation around the ankles (due to hemosiderin deposition from blood pooling), and swelling.

A. Second or third intercostal space at the left sternal border B. The second intercostal space at the right sternal border C. Fifth intercostal space near the left midclavicular line D. Third intercostal space at the left sternal border

Correct Answer is A

Explanation

Rationale:
A. Second or third intercostal space at the left sternal border: Erb's point is located here, and it's a key area for listening to heart sounds, particularly the aortic and pulmonic valves.

B. The second intercostal space at the right sternal border: This area is typically used to auscultate the aortic valve.

C. Fifth intercostal space near the left midclavicular line: This area is used to auscultate the mitral valve, not Erb's point.

D. Third intercostal space at the left sternal border: This is the location for listening to the pulmonic valve, not Erb's point.

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The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

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Naxlex Comprehensive Predictor Exams

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Correct Answer is D

Explanation

The traditional areas of auscultation of heart sounds include Erb's point, which is located at?

Correct Answer is A

Explanation

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A positive Murphy's sign is indicative of?

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

A mitral insufficiency/regurgitation murmur is classified as:

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