The nurse auscultates the client’s abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?

Auscultate for another 4 minutes.

Listen for another minute just to be sure.

Contact the physician as this is a surgical emergency.

Listen posteriorly for enhanced bowel sounds.

Answer and Explanation

The Correct Answer is B

The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be aﬀected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.

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Correct Answer is ["A"]

Explanation

To map the client's abdomen into four quadrants, the nurse should use the umbilicus as the landmark to perform this assessment. The abdomen is divided into four quadrants by drawing an imaginary line from the center of the umbilicus to the pubic symphysis and another line from the center of the umbilicus to the xiphoid process of the sternum. This helps in identifying the location of any potential abdominal discomfort or tenderness.

A. Upper outer quadrant B. Lower inner quadrant C. Upper inner quadrant D. Tail of spence

Correct Answer is ["A","B","C"]

Explanation

The nurses would teach the patient to palpate all four quadrants of the breast, including the upper outer quadrant, lower inner quadrant, and upper inner quadrant, as well as the tail of Spence, which is the extension of breast tissue into the axilla (armpit). It's important for the patient to be familiar with their own breast tissue and report any changes or abnormalities to their healthcare provider.

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The nurse auscultates the client’s abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is mapping the client’s abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)

Correct Answer is ["A"]

Explanation

When assessing the breast, the nurse would teach the patient to palpate which of the following areas?

Correct Answer is ["A","B","C"]

Explanation

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