A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?

Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in).

Auscultate each of the four quadrants for 5 min before determining sounds are absent.

Percuss each of the four quadrants of the abdomen.

Inspect each of the four quadrants for abdominal distention.

Answer and Explanation

The Correct Answer is B

A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in): Palpation assesses tenderness, masses, or organ enlargement but does not evaluate peristalsis. Palpating too soon postoperatively can also cause discomfort or disrupt healing.

B. Auscultate each of the four quadrants for 5 min before determining sounds are absent: Bowel sounds indicate peristalsis, and a full 5 minutes of auscultation is required before concluding they are absent, especially after abdominal surgery where bowel activity may be reduced.

C. Percuss each of the four quadrants of the abdomen: Percussion evaluates the presence of fluid, gas, or organ borders but does not provide information about bowel motility. It is useful for assessing distention but not peristalsis.

D. Inspect each of the four quadrants for abdominal distention: Inspection identifies visible abnormalities such as distention, scars, or pulsations. While distention may suggest reduced peristalsis, visual inspection alone does not confirm bowel activity.

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Correct Answer is C

Explanation

A. Change the secondary IV infusion set twice weekly: Secondary IV sets, such as piggyback infusions, should generally be changed every 24 hours to reduce the risk of contamination and infection. Changing them twice weekly would not maintain proper asepsis.

B. Change a continuously infusing IV bag after 48 hr: Continuous IV bags should be replaced at least every 24 hours to prevent bacterial growth. Waiting 48 hours increases the risk of microbial contamination and bloodstream infections.

C. Change the primary IV infusion set every 96 hr: Changing the primary IV infusion set every 96 hours (4 days) aligns with standard infection-control guidelines. This interval helps maintain asepsis while minimizing the risk of IV-related infections.

D. Change the extension tubing once per week: Extension tubing connected to the IV line should be changed more frequently, typically every 72 to 96 hours, to prevent contamination. Once per week is too infrequent and increases infection risk.

A. An older adult client who began volunteering at a local clinic following their partner's death B. An adolescent client who reports spending more time with friends than close family C. A client who is being discharged to a rehabilitation facility rather than home following surgery D. A client who is terminally ill and whose family members are in denial of the impending death

Correct Answer is D

Explanation

A. An older adult client who began volunteering at a local clinic following their partner's death: Volunteering encourages social interaction and helps prevent loneliness. This client is actively engaging with others, which reduces the likelihood of isolation.

B. An adolescent client who reports spending more time with friends than close family: Adolescents commonly shift toward peer-centered relationships. Spending more time with friends than family is developmentally appropriate and does not indicate social isolation.

C. A client who is being discharged to a rehabilitation facility rather than home following surgery: While moving to a facility may temporarily disrupt social networks, rehabilitation centers provide structured interactions with staff and other clients, reducing the risk of isolation.

D. A client who is terminally ill and whose family members are in denial of the impending death: This client faces a greater risk of social isolation because the family’s denial can limit open communication and emotional support. The client may feel alone in processing their condition and preparing for end-of-life needs.

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A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?

Nursing Test Bank

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