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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Thigh muscles: While thigh muscles assist in venous return, they are not as critical as the calf muscles in moving blood from the feet.
B. Arterial pulsations: Arterial pulsations help in the forward movement of blood in the arteries but do not directly assist with venous return from the feet.
C. Venous flow: Venous flow is the general term for blood movement in veins, but it does not specify the mechanism responsible for moving blood from the feet.
D. Calf muscles: The calf muscles, through their contraction (often referred to as the "muscle pump"), are crucial in helping to push blood upwards from the feet towards the inferior vena cava. This mechanism is essential for effective venous return.
Correct Answer is B
Explanation
A. S3: This sound is associated with early diastole, often related to heart failure or volume overload.
B. S1: The first heart sound (S1) marks the beginning of systole and corresponds to the closure of the mitral and tricuspid valves.
C. S2: The second heart sound (S2) indicates the end of systole and the beginning of diastole, associated with the closure of the aortic and pulmonic valves.
D. S4: This sound is associated with late diastole, often related to decreased ventricular compliance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.