The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?
Reduce all environmental noise.
Percuss the region before auscultating.
Palpate the region before auscultating.
Assist the client to a sitting position.
The Correct Answer is A
A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.
B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.
C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.
D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. VII: The Facial nerve (VII) is responsible for taste sensation in the anterior two-thirds of the tongue. An inability to taste in this area indicates a dysfunction in this nerve.
B. XII: The Hypoglossal nerve (XII) controls tongue movements but does not involve taste sensation.
C. V: The Trigeminal nerve (V) provides sensation to the face and mouth but is not responsible for taste.
D. II: The Optic nerve (II) is involved in vision, not taste.
Correct Answer is A
Explanation
A. Pulses: The finger pads are particularly effective for detecting the presence, strength, and regularity of pulses due to their sensitivity and the ability to apply gentle pressure.
B. Vibrations: Vibrations are best assessed with the ulnar surface of the hand rather than the finger pads.
C. Fremitus: Fremitus, or the vibrations transmitted through the chest wall, is best assessed using the palmar or ulnar surface of the hand.
D. Temperature: Temperature is more effectively assessed using the back of the hand, not the finger pads.
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