The practical nurse (PN) is collecting data from a client who was seen three days ago for a puncture wound on the left lower calf. Upon return to the clinic, the client reports increased pain, limited range of motion in the left leg, and overall achiness and chills. Which finding(s) indicate possible infection? Select all that apply.

Rationale:

A. Inspect the urethral meatus for discharge: Examining the urethral meatus is primarily indicated when infection or inflammation, such as urethritis, is suspected. While discharge could indicate a problem, the client’s main concern involves urinary hesitancy and nocturia, making this assessment less directly relevant.

B. Observe the scrotum for swelling: Scrotal inspection is important for conditions such as hydrocele or testicular masses. These findings are not typically associated with nocturia or difficulty initiating urination in older males, so this assessment would not provide focused information for the client’s current urinary symptoms.

C. Palpate the inguinal area for a bulge: Assessing the inguinal area can detect hernias, which may cause discomfort or urinary issues indirectly, but it does not address the primary complaints of urinary hesitancy and frequency, and is therefore not the most pertinent assessment.

D. Question client about urinary dribbling and frequency: Asking about urinary dribbling, frequency, and stream characteristics directly evaluates symptoms associated with benign prostatic hyperplasia or lower urinary tract obstruction. This focused history provides critical information to guide further assessment and intervention for the client’s nocturia and difficulty initiating urination.

Rationale:

A. Turn the suction off while auscultating: The nasogastric tube connected to low intermittent suction can create artificial sounds that may mimic or obscure true bowel activity. Temporarily discontinuing suction allows for accurate assessment of intestinal peristalsis without interference.

B. Use a warmed bell of the stethoscope and place it lightly over the four quads: Bowel sounds are high-pitched. The diaphragm of the stethoscope is used for high-pitched sounds (bowel, lung, normal heart sounds), while the bell is used for low-pitched sounds (bruits or extra heart sounds).

C. Palpate the abdomen before auscultating: Palpation prior to auscultation can stimulate peristalsis and alter the natural frequency and character of bowel sounds. This interferes with obtaining an accurate baseline assessment of gastrointestinal activity. Standard abdominal assessment technique prioritizes auscultation before palpation.

D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent: Postoperative clients, after abdominal surgery, may have decreased or absent bowel sounds due to ileus. Prolonged auscultation for at least 5 minutes in a quadrant is necessary before concluding absence, as bowel sounds can be infrequent and irregular.

E. Place the stethoscope in the ears with the earpieces pointing towards the ears: To follow the natural shape of the ear canal and maximize sound quality, the earpieces should point forward (toward the nose), not backward toward the ears/back of the head.