The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

"We need to determine the areas of tenderness before using percussion and palpation."

"Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination."

"Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation."

"Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

Answer and Explanation

The Correct Answer is C

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

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Correct Answer is B

Explanation

A. 1 minute: This is not the correct duration for assessing bowel sounds.

B. 2 minutes each quadrant: Bowel sounds should be auscultated for at least 2 minutes per quadrant before determining that they are absent.

C. 5 minutes: Listening for 5 minutes is excessive and typically unnecessary unless there is concern about a complete absence of bowel sounds.

D. 10 minutes: 10 minutes is also too long for auscultation unless specifically indicated by clinical findings, like suspected paralytic ileus.

A. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm. B. Refer the individual for further evaluation. C. Check for the presence of claudication. D. Consider this finding as normal, and proceed with the peripheral vascular evaluation.

Correct Answer is D

Explanation

A. Asking about cramping or tingling is unnecessary without other signs of compromised circulation.

B. Referral is not needed if perfusion is adequate.

C. Checking for claudication relates to arterial insufficiency, not absence of ulnar pulse.

D. Proceeding with the evaluation is appropriate if perfusion is adequate, as indicated by normal capillary refill and warm skin.

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The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is B

Explanation

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

Correct Answer is D

Explanation

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