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 B
Explanation
A. S2: This sound, also known as "dub," occurs during diastole when the semilunar valves close.
B. S1: This sound, also known as "lub," occurs during systole when the atrioventricular valves close, marking the beginning of systole.
C. S4: This sound is an abnormal heart sound associated with late diastole, not systole.
D. S3: This sound is associated with early diastole and is typically related to rapid ventricular filling, not systole.
Correct Answer is C
Explanation
A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.
B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.
C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.
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