When auscultating a client's abdomen, the practical nurse (PN) listens for bowel sounds for three minutes without hearing any peristaltic sounds. Which action should the PN take?
Continue to auscultate the abdomen for a longer time period.
Determine if the client needs to empty his bladder.
Ask the client to flex his knees to relax the abdomen.
Notify the charge nurse of the absence of bowel sounds.
The Correct Answer is A
A. Continue to auscultate the abdomen for a longer time period: Absence of bowel sounds should be confirmed after listening for 5 minutes in each quadrant before reporting.
B. Determine if client needs to empty bladder: Not related to bowel sounds.
C. Ask client to flex knees to relax the abdomen.: May relax abdomen but does not confirm bowel activity.
D. Notify charge nurse of the absence of bowel sounds: Only after confirming prolonged absence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Review the client's vital signs for indications of infection:
Interpreting vital signs requires nursing judgment; not a UAP task.
B. Reassure the client that phantom limb pain is genuine pain:
Providing emotional reassurance is within the PN’s role, not UAP’s.
C. Observe and mark the amount of drainage on the dressing:
Assessment and documentation are PN responsibilities.
D. Empty and measure the drainage in the suction drainage device:
UAPs can perform this task under direction since it is a measurable, routine activity.
Correct Answer is C
Explanation
A. Raise the pitch of your voice and speak slower: Higher pitch may make it harder for older adults to hear; slowing speech can help but low pitch is better.
B. Sit with light of window behind you: Causes glare and makes lip reading harder.
C. Restate questions articulating consonants carefully: Clear articulation improves comprehension without straining the voice.
D. Stand above client and speak loudly: Loudness can distort sound and is uncomfortable.
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