The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise.

Percuss the region before auscultating.

Palpate the region before auscultating.

Assist the client to a sitting position.

Answer and Explanation

The Correct Answer is A

A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.

B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.

C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.

D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.

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Correct Answer is C

Explanation

A. Technician: Technicians generally perform specific tasks or tests rather than collecting comprehensive subjective data.

B. Secretary: A secretary's role is administrative and does not involve direct patient assessment or data collection.

C. Nurse: Nurses are typically responsible for collecting subjective data from clients during the initial comprehensive assessment, including patient history and current health concerns.

D. Physician: While physicians review and interpret data, they often rely on nurses to collect detailed subjective information during initial assessments.

A. History of present illness B. Initial Information C. Review of Systems D. Health Patterns

Correct Answer is A

Explanation

A. History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.

B. Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.

C. Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.

D. Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.

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The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?

Correct Answer is C

Explanation

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

Correct Answer is A

Explanation

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

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The nurse instructs a female client on breast self-examination. Why does the nurse recommend the pattern shown for the client to use?

Data collection occurs where in the nursing process?

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The nurse would palpate the axillae during examination of which area?

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