The physician orders Ancef 500 mg IV for a urinary tract infection.

After reconstitution, the medication is available as 330 mg/mL. How many milliliters will the nurse administer?

Choice A rationale

Auscultation of the abdomen for bowel sounds should be performed prior to any manipulation such as inspection, palpation, or percussion. Palpation and percussion can stimulate or inhibit bowel motility, potentially altering the sounds heard and leading to an inaccurate assessment of baseline bowel activity.

Choice B rationale

Palpating the abdomen involves applying pressure, which can stimulate bowel motility and increase bowel sounds. Auscultating after palpation might not reflect the client's true baseline bowel sounds.

Choice C rationale

Checking for kidney tenderness involves percussing the costovertebral angle, which is located on the back and does not directly impact bowel sounds. However, it is still a form of manipulation that should ideally occur after auscultation of the abdomen to avoid any potential influence on bowel sounds.

Choice D rationale

Percussion of the abdomen involves tapping the abdominal surface to assess underlying structures. This manipulation can also alter bowel motility and the characteristics of bowel sounds. Therefore, auscultation should precede percussion for an accurate assessment.

Choice A rationale

Normoactive bowel sounds are the typical, intermittent gurgling sounds heard during a bowel assessment, indicating normal peristalsis and intestinal activity. The absence of any sounds for 30 seconds suggests a significant reduction or cessation of this activity, which is not consistent with normoactive findings.

Choice B rationale

Hypoactive bowel sounds are characterized by infrequent and faint gurgling sounds, indicating a decrease in intestinal motility. While a pause of 30 seconds without any sounds might precede hypoactive sounds, the complete absence of sounds for this duration is more indicative of a further reduction in bowel activity than simply hypoactivity.

Choice C rationale

Absent bowel sounds are documented when no bowel sounds are heard after listening in each of the four abdominal quadrants for a specified period, typically ranging from 2 to 5 minutes per quadrant. A 30-second period without any sounds in one area is a significant finding that should be documented as absent in that specific quadrant, warranting further assessment.

Choice D rationale

Hyperactive bowel sounds are loud, high-pitched, and frequent gurgling sounds, often described as "borborygmi" or stomach rumbling. These sounds indicate increased intestinal motility, which is the opposite of the finding of no bowel sounds for 30 seconds.