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 D

Explanation

A. "Do you take any recreational drugs?"

This question is related to the risk of hepatitis transmission through the sharing of needles or other drug paraphernalia. Hepatitis B and C can be transmitted through contaminated needles used for injecting drugs.
B. "Did you have a blood transfusion recently?"

This question addresses the risk of hepatitis transmission through blood transfusions. While this used to be a significant risk, modern blood screening procedures have greatly reduced this risk. However, it's still a relevant question to understand the client's medical history.
C. "Have you eaten any shellfish lately?"

This question is related to the risk of hepatitis A transmission. Hepatitis A is often transmitted through contaminated food or water. Shellfish from contaminated waters can be a source of hepatitis A infection.
D. "Have you traveled to a third world country in the past two months?"

This question is crucial because hepatitis A is often more prevalent in developing countries and can be contracted through contaminated food, water, or poor sanitation. Travel history can help identify possible exposure sources.

A. Perform leg exercises every 2 hr. B. irrigate the nasogastric tube every 4 to 8 hr. C. Maintain bed rest for 48 hr following surgery. D. Encourage hourly use of an incentive spirometer while awake. E. Document the color, consistency, and amount of nasogastric drainage.

Correct Answer is ["A","D","E"]

Explanation

A. Perform leg exercises every 2 hr: Performing leg exercises every 2 hours is essential for preventing blood clots and maintaining circulation in immobile patients. This is especially important after surgery to prevent complications like deep vein thrombosis.

B. Irrigate the nasogastric tube every 4 to 8 hr: Irrigating the nasogastric tube is not a standard nursing practice and should not be done without a physician's order. The nasogastric tube is typically used for decompression, drainage, or feeding. If the tube becomes clogged or there are concerns about drainage, the nurse should contact the healthcare provider for further instructions.

C. Maintain bed rest for 48 hr following surgery: While some bed rest might be necessary immediately after surgery, the goal is to encourage mobility as soon as possible to prevent complications such as atelectasis and deep vein thrombosis. Patients are usually encouraged to mobilize as soon as they are medically stable, often within hours after surgery.

D. Encourage hourly use of an incentive spirometer while awake: Using an incentive spirometer helps prevent atelectasis and promotes lung expansion after surgery. Encouraging the patient to use the incentive spirometer hourly while awake is a common nursing intervention to maintain respiratory function postoperatively.

E. Document the color, consistency, and amount of nasogastric drainage: Documenting the color, consistency, and amount of nasogastric drainage is crucial for monitoring the patient's condition. Changes in these factors could indicate bleeding, infection, or other complications, and timely documentation helps healthcare providers assess the patient's status and make appropriate interventions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hepatitis A. The client asks the nurse how he might have contracted the virus. Before responding, which of the following questions should the nurse first ask the client?

Correct Answer is D

Explanation

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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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