A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

Prior to inspecting the abdomen

After checking int kidney tenderness

After palpating the abdomen

Answer and Explanation

The Correct Answer is A

A. Prior to percussing the abdomen
Bowel sounds are typically auscultated before performing any other abdominal assessments. This allows the nurse to get an accurate representation of the client's bowel activity without any interference from other assessment techniques.

B. Prior to inspecting the abdomen
Inspecting the abdomen involves observing for any visible abnormalities, such as distension or lesions. Bowel sounds are auscultated first to get an initial sense of the client's gastrointestinal activity.

C. After checking for kidney tenderness
Kidney tenderness assessment is not directly related to bowel sounds. These assessments are separate and do not impact each other's sequence.

D. After palpating the abdomen
Palpating the abdomen should be done after auscultation. Palpation can stimulate bowel activity, potentially altering the natural bowel sounds. Therefore, it is essential to auscultate the abdomen before palpating it.

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Correct Answer is C

Explanation

A. Check the client for a positive Chvostek's sign.
Chvostek's sign is a clinical sign of hypocalcemia (low calcium levels), not related to the client's potassium levels. The given potassium level is low, not calcium.

B. Discontinue the TPN infusion.
While the potassium level is low, discontinuing TPN without addressing the potassium deficiency can lead to further complications. TPN can be adjusted to include potassium supplementation.

C. Request a potassium replacement.
The client's low potassium level (3.0 mEq/L) requires potassium replacement. This can be done through the TPN solution or via a separate IV infusion. This choice is correct.

D. Administer glucagon IM.
Glucagon is not used to treat low potassium levels.

A. Diabetes mellitus B. Hepatitis A C. Cirrhosis D. Cholecystitis

Correct Answer is C

Explanation

A. Diabetes mellitus
Diabetes mellitus can cause easy bruising and slow wound healing, but it is not typically associated with frequent nosebleeds.

B. Hepatitis A
Hepatitis A primarily affects the liver and does not cause frequent bruising and nosebleeds.

C. Cirrhosis
Cirrhosis, which is scarring of the liver tissue due to long-term liver damage, can lead to impaired liver function. One consequence of cirrhosis is decreased production of clotting factors, which can result in easy bruising. Additionally, the enlarged spleen in cirrhosis can lead to thrombocytopenia (low platelet count), contributing to bleeding tendencies, including nosebleeds. Cirrhosis is the most likely condition given the symptoms described.

D. Cholecystitis
Cholecystitis is inflammation of the gallbladder and is not directly associated with frequent bruising and nosebleeds.

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A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

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Naxlex Comprehensive Predictor Exams

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