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 C

Explanation

A. Wound infection: While important to address, a wound infection does not directly impact airway, breathing, or circulation unless it leads to severe complications.

B. Bacteremia: This condition is serious and can lead to sepsis, which affects circulation, but immediate airway and breathing issues take precedence.

C. Aspiration pneumonia: This directly affects breathing by causing respiratory complications, making it a priority when considering airway and breathing issues.

D. Urinary tract infection: Although it requires treatment, it does not immediately impact airway, breathing, or circulation like aspiration pneumonia can.

A. XII B. V C. VII D. XI

Correct Answer is C

Explanation

A. XII: Cranial nerve XII (hypoglossal) controls tongue movements, but is not typically assessed by the technique described.

B. V: Cranial nerve V (trigeminal) is assessed for facial sensation and mastication, not the technique in question.

C. VII: Cranial nerve VII (facial) is responsible for facial expressions and is assessed by asking the client to perform various facial movements.

D. XI: Cranial nerve XI (accessory) is involved in shoulder and neck movements, not facial expressions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When applying the principle of ABC (airway, breathing, circulation) prioritization, which complication is priority for the nurse to address?

Correct Answer is C

Explanation

The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

Correct Answer is C

Explanation

When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Which type of assessment includes a health history and physical assessment?

Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

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A positive Murphy's sign is indicative of?

The nurse would palpate the axillae during examination of which area?

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?

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