After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Elevate the head of the client's bed immediately.

Use the bell of the stethoscope to auscultate again.

Document the presence of borborygmi.

Auscultate the remaining two quadrants.

Answer and Explanation

The Correct Answer is C

Answer: C. Document the presence of borborygmi.

Rationale:

A. Elevate the head of the client's bed immediately:
While elevating the head of the bed may be appropriate in certain situations, it is not the necessary immediate action in this context. The presence of loud, high-pitched bowel sounds does not indicate a need for repositioning the client. Instead, the nurse should first focus on assessing the findings before making any positional changes.

B. Use the bell of the stethoscope to auscultate again:
The bell of the stethoscope is typically used for lower frequency sounds, such as heart murmurs or certain vascular sounds. Since the nurse has already identified high-pitched bowel sounds using the diaphragm, switching to the bell is not appropriate for this situation. The diaphragm is better suited for detecting the types of sounds the nurse is hearing.

C. Document the presence of borborygmi:
Borborygmi refers to the loud, gurgling bowel sounds that can indicate increased intestinal activity. Documenting this finding is essential as it provides a clear record of the client's bowel sounds at this moment. This documentation can aid in monitoring the client's gastrointestinal function and is crucial for continuity of care.

D. Auscultate the remaining two quadrants:
While it is important to auscultate all quadrants to get a complete assessment of bowel sounds, the immediate action after hearing significant sounds in two quadrants is to document the findings. Continuing the assessment can follow, but the documentation serves as an important step in patient care and communication among the healthcare team.

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Correct Answer is B

Explanation

B. Cardiac enlargement:
This is the most likely interpretation of the findings. A significant area of dullness across a larger portion of the chest, as described, suggests that the heart is enlarged (cardiomegaly). Enlargement of the heart may result from various conditions, such as heart failure, hypertension, or valvular disease, leading to increased cardiac size and the shift in the percussion borders. This could indicate that the heart has expanded beyond its normal anatomical limits, and further assessment, such as imaging, would be necessary to confirm the diagnosis.

A. A 2-year-old who is demonstrating diaphragmatic breathing. B. A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2. C. A 75-year-old with a pneumothorax and a chest tube. D. A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg).

Correct Answer is D

Explanation

A) A 2-year-old who is demonstrating diaphragmatic breathing:
In young children, especially infants and toddlers, the PMI is typically easier to locate due to their smaller size and thinner chest wall. Diaphragmatic breathing, which is normal in infants and toddlers, does not necessarily interfere with locating the PMI.

B) A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2:
A BMI within the normal range does not necessarily affect the ability to locate the PMI. Additionally, physical fitness, such as being a long-distance runner, may contribute to better cardiovascular health and clearer identification of the PMI.

C) A 75-year-old with a pneumothorax and a chest tube:
In clients with a pneumothorax and a chest tube, the presence of medical devices and underlying respiratory conditions may affect the ability to locate the PMI. However, the primary challenge here would likely be due to the presence of the chest tube rather than the client's age alone.

D) A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg):
In individuals who are significantly overweight or obese, locating the PMI may be challenging due to increased chest wall thickness and adipose tissue. The increased depth of tissue can make palpating the PMI more difficult, leading to anticipated difficulty in locating it accurately.

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After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Rationale:

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Naxlex Comprehensive Predictor Exams

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

Correct Answer is D

Explanation

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