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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.
Correct Answer is A
Explanation
A. The Cowper gland, also known as the bulbourethral gland, secretes a thin, milky alkaline fluid that neutralizes acidity in the urethra and enhances sperm viability.
B. The prostate gland secretes a milky, slightly acidic fluid that nourishes and protects sperm, contributing to semen volume.
C. The bulbourethral gland (Cowper gland) is responsible for producing the thin, alkaline fluid that neutralizes the urethra and enhances sperm viability.
D. The median sulcus refers to a groove or depression on the surface of an organ and is not associated with secretion in the reproductive system.
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