The nurse is caring for a client who is one day post op after having abdominal surgery. While auscultating bowel sounds for a full one minute, the nurse hears 3 bowel sounds. The nurse would chart this as bowel sounds.

hyperactive

active

hypoactive

absent

Answer and Explanation

The Correct Answer is C

In a postoperative client one day after abdominal surgery, hearing only 3 bowel sounds in one minute indicates hypoactive bowel sounds. Normal bowel sounds are typically described as "active" and occur at a rate of 5 to 30 per minute. Hypoactive bowel sounds are decreased in frequency, often occurring less than 5 per minute, and may indicate decreased gastrointestinal motility, which is common after abdominal surgery due to factors such as anesthesia, pain medication, and bowel manipulation during surgery.

A. Hyperactive: Hyperactive bowel sounds, also known as "borborygmi," are increased in frequency and intensity. They are often loud, gurgling sounds and may indicate increased gastrointestinal motility or the presence of diarrhea. This description does not fit the scenario described.

B. Active: While "active" bowel sounds are within the normal range, hearing only 3 bowel sounds in one minute suggests decreased frequency, indicating hypoactivity rather than normal activity.

C. Hypoactive: Hypoactive bowel sounds are decreased in frequency, occurring less than 5 per minute. This finding is commonly observed in postoperative clients due to factors such as anesthesia and opioid pain medication.

D. Absent: Absent bowel sounds are concerning and may indicate ileus or bowel obstruction. In this scenario, hearing 3 bowel sounds indicates some bowel motility, ruling out the classification of absent bowel sounds.

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Correct Answer is B

Explanation

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.

A. Multiple lesions on dorsal aspect of feet probably due to elder abuse B. Four burned areas noted on plantar area of each foot C. Several partially healed lesions on bottom of left foot, looks like cigarette burns D. Four round, 2 cm in diameter lesions on plantar aspect of right foot

Correct Answer is D

Explanation

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

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The nurse is caring for a client who is one day post op after having abdominal surgery. While auscultating bowel sounds for a full one minute, the nurse hears 3 bowel sounds. The nurse would chart this as bowel sounds.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which position would be appropriate for the nurse to perform an abdominal assessment?

Correct Answer is B

Explanation

What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Correct Answer is D

Explanation

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