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 ["A","D","E"]

Explanation

A. Perform leg exercises every 2 hr:
After surgery, especially abdominal surgery, patients are at risk of developing deep vein thrombosis (DVT) due to decreased mobility. Performing leg exercises every 2 hours helps in improving blood circulation and preventing blood clots in the legs.

B. Irrigate the nasogastric tube every 4 to 8 hr:
Irrigating the nasogastric tube (inserting fluid into the tube) at regular intervals is not a standard practice. Nasogastric tubes are primarily used for decompression (removing stomach contents) or drainage, not for irrigation. Inserting fluids without a specific medical reason can disrupt the balance in the gastrointestinal tract and lead to complications.

C. Maintain bed rest for 48 hr following surgery:
Encouraging early mobility is a standard practice after surgery. Prolonged bed rest increases the risk of complications such as pneumonia, blood clots, and muscle weakness. Patients are typically encouraged to start moving and walking around as soon as it's safe to do so, usually within a few hours to a day after surgery, depending on the type of surgery and the patient's overall condition.

D. Encourage hourly use of an incentive spirometer while awake:
An incentive spirometer is a medical device used to help patients improve the functioning of their lungs. It encourages patients to take slow, deep breaths, which helps in expanding the lungs and preventing atelectasis (partial lung collapse) that can occur after surgery when patients may not be taking deep breaths as usual.

E. Document the color, consistency, and amount of nasogastric drainage:
Monitoring and documenting the characteristics of nasogastric drainage is essential for assessing the patient's condition. Changes in the color, consistency, or amount of drainage can indicate various issues, including bleeding, infection, or bowel perforation. This documentation helps the healthcare team make informed decisions about the patient's care.

A. Percuss B. Auscultate. C. Palpate. D. Inspect

Correct Answer is D

Explanation

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

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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

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

Explanation

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Correct Answer is D

Explanation

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