The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Perform abdominal percussion, and then repeat auscultation.

Palpate the client's abdomen to stimulate bowel motility.

Repeat auscultation in four to six hours.

Listen for five minutes before documenting an absence of bowel sounds.

Answer and Explanation

The Correct Answer is D

A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.

B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.

C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.

D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant

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Correct Answer is B

Explanation

A. Diaphragm on one side, bell on the opposite side: Suitable for a full cardiac examination, as it can assess both high and low-frequency sounds.

B. Diaphragm Only: Less suitable for a full cardiac examination because it may not effectively capture low-frequency sounds such as certain heart murmurs.

C. Bell on one side, Diaphragm on the opposite side: Effective for a full cardiac examination, as it can assess both high and low-frequency sounds.

D. Diaphragm and bell on same side: Allows for a complete assessment of heart sounds, though it may be less versatile than separate components on each side.

A. Auscultate the anatomic area with a stethoscope. B. Use Doppler ultrasonography to locate the pulse. C. Ask another nurse to assess the pulse. D. Document absence of dorsalis pedis pulse.

Correct Answer is B

Explanation

A. Auscultating the area may not provide accurate information about the pulse if it is not palpable, though it can be part of the assessment if Doppler is unavailable.

B. Using Doppler ultrasonography is the most appropriate next step to accurately assess the pulse if it is not palpable, especially in older adults where pulses may be difficult to detect.

C. Asking another nurse to assess the pulse may not address the underlying issue of why the pulse is not palpable and does not provide additional information.

D. Documenting the absence of the dorsalis pedis pulse without further investigation could be premature, as Doppler ultrasonography should be used to confirm its absence.

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The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

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Naxlex Comprehensive Predictor Exams

Of the four types of stethoscopes, which one is most unsuitable to conduct a full cardiac examination?

Correct Answer is B

Explanation

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?

Correct Answer is B

Explanation

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