A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

After palpating the abdomen

Prior to percussing the abdomen

Prior to inspecting the abdomen

After assessing for kidney tenderness

Answer and Explanation

The Correct Answer is B

A.   After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B.   Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C.   Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D.   After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

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Correct Answer is A

Explanation

A. Wearing synthetic clothing and woolen socks can generate static electricity, which poses a fire hazard in the presence of oxygen. The client should be advised to wear cotton or natural fiber clothing, which is less likely to generate static electricity.
B. "I will make sure my visitors smoke outside" is a correct statement. It is important to avoid smoking or open flames near oxygen equipment, as oxygen is highly flammable.
C. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter" is a correct statement. The flowmeter indicates the rate of oxygen delivery in liters per minute.
D. "I should call my doctor if I find it harder to concentrate" is a correct statement.
Changes in mental alertness or concentration can be a sign of inadequate oxygenation and should be reported to the healthcare provider.

A. Elevate the bed to a position of comfort for the nurse. B. Acquire the help of several people to lift the client. C. Place the wheelchair at a 90° angle to the bed. D. Lock the wheels of the bed and the wheelchair.

Correct Answer is D

Explanation

A. Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B. While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C. This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D. Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.

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A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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