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 ["A","D","E"]
Explanation
A. Record automatic blood pressure readings: Measuring and recording vital signs is part of the assessment phase.
B. Develop the initial plan of care: This is part of the planning phase, not assessment.
C. Initiate range of motion exercises: This is part of implementation, not assessment.
D. Gather information about the client's symptoms: Collecting subjective data is part of assessment.
E. Observe for muscle weakness and fatigue: Gathering objective data by observation is part of assessment.
Correct Answer is D
Explanation
A. Foreign body:
Not a contraindication for ketorolac use; removal is priority.
B. Chemical burn:
Requires irrigation and emergency care, not NSAID eye drops.
C. Radiation exposure:
May cause eye irritation but not a contraindication for ketorolac.
D. Corneal abrasion:
Ketorolac can delay healing of corneal abrasions; contraindicated.
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