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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

A. "Is the pain worse on exertion?" B. "Is the pain worse when you are lying down?" C. "Do you have any pain or discomfort in your chest?" D. "Do you have cramping pain?"

Correct Answer is C

Explanation

A. "Is the pain worse on exertion?": While this is an important question for assessing cardiac risk, it is secondary to identifying any chest pain.

B. "Is the pain worse when you are lying down?": This question is more relevant for assessing musculoskeletal or gastrointestinal issues rather than cardiac risk.

C. "Do you have any pain or discomfort in your chest?": Chest pain or discomfort is a primary symptom associated with cardiac events, making this the most critical question to ask first.

D. "Do you have cramping pain?": This is not specific enough to determine cardiac risk and is more related to gastrointestinal or muscle-related issues.

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The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

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Naxlex Comprehensive Predictor Exams

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of

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Explanation

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Correct Answer is C

Explanation

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