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. Obtain the client's vital signs:
Vital signs are essential for assessing the client's overall condition and can provide crucial information about the client's stability. However, in this scenario, there's a higher priority nursing action that needs immediate attention.

B. Weigh the client:
Daily weight measurement is important, especially in postoperative patients, to monitor for fluid retention or loss. However, this is not the most urgent action in this situation.

C. Change the client's dressing:
Changing the dressing involves maintaining the surgical site's cleanliness and preventing infections. While this is important, it's not the highest priority in this situation.

D. Administer pain medication:
Correct Choice. Addressing the client's pain is a priority to ensure their comfort and well-being, especially postoperatively. Managing pain effectively is crucial for the client's recovery and can facilitate other necessary activities, such as changing the dressing or weighing the client.

A. Check the client for a positive Chvostek’s sign B. Discontinue the TPN infusion. C. Request a potassium replace D. Administer glucagon IM

Correct Answer is C

Explanation

A. Check the client for a positive Chvostek’s sign:
Chvostek's sign is a clinical sign of hypocalcemia, not related to the given laboratory values. The symptoms include facial muscle twitching when the facial nerve (VII) is tapped. There's no indication for this assessment based on the provided information.

B. Discontinue the TPN infusion:
The glucose level is within the normal range (70-99 mg/dL). Discontinuing TPN based solely on this glucose level is not warranted.

C. Request a potassium replacement:
The potassium level is low (normal range typically 3.5-5.0 mEq/L). Given the low potassium level, the nurse should plan to request a potassium replacement. Potassium is crucial for various physiological functions, and a deficiency can lead to significant complications.

D. Administer glucagon IM:
Glucagon is used to treat hypoglycemia, but the client's glucose level is within the normal range, so administering glucagon is not indicated.

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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

Correct Answer is D

Explanation

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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