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. The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.

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 to a comfortable position for the nurse is important to prevent strain or injury to the nurse's back. However, this action alone does not ensure the client's safety during the transfer.
- B) While acquiring help can be useful, especially for a heavy client or one with limited mobility, it is not the primary action to ensure safety during the transfer.
- C) Placing the wheelchair at a 90° angle to the bed may make the transfer more difficult because it does not allow for the most direct path to the wheelchair.
- D) Locking the wheels of both the bed and the wheelchair is the correct action to take to ensure stability and prevent movement, providing a safe transfer for the client.

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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?

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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