During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

1 minute in the center of the abdomen.

10 minutes in each quadrant.

1 minute in each quadrant.

5 minutes in each quadrant.

None

Answer and Explanation

The Correct Answer is D

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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Correct Answer is A

Explanation

A. Heart failure can lead to fluid accumulation in the legs due to the heart's inability to effectively pump blood, causing increased pressure in the veins.
B. Excess fluid retention or consumption might cause edema, but heart failure specifically impacts the heart's pumping function.
C. Excess fluid consumption might contribute to temporary edema, but severe bilateral lower extremity edema is more likely due to a systemic issue like heart failure.
D. While a pulmonary embolism can lead to edema in the legs, it typically presents with sudden onset and might not present with bilateral edema from feet to knees.

A. "A good time to examine your testicles is just before you take a shower." B. "If you notice an enlarged testicle or a painless lump, call your health care provider." C. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer." D. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency."

Correct Answer is B

Explanation

A. Timing for testicular examination isn't as crucial as recognizing changes in the testicles. While showering might facilitate the exam, it's not the only appropriate time.
B. Noticing an enlargement or painless lump is a crucial sign that requires immediate medical attention for evaluation.
C. Performing a testicular examination once a week might not be necessary for most individuals. Monthly self-examination is often recommended.
D. Describing the testicle's normal characteristics is helpful, but recognizing changes such as lumps or enlargements is more critical for self-examination.

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During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?

Correct Answer is B

Explanation

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