° Cognitive Ability: Applying ° Client Needs: Physiological Integrity

° Integrated Process: Communication and Documentation ° Content Area: Adult Health/Gastrointestinal Awarded 1.0 points out of 1.0 possible points. ° 54. ID: 8482581643 A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant Correct ° Rationale: When auscultating bowel sounds, the nurse uses the diaphragm endpiece, because bowel sounds are relatively high pitched. The nurse holds the stethoscope lightly against the skin, because pushing too hard could stimulate more bowel sounds. The nurse begins auscultating in the right lower quadrant at the ileocecal valve, because bowel sounds are normally always present there. The nurse then listens for bowel sounds in the other quadrants. ° Test-Taking Strategy: Knowledge of the procedure for auscultating bowel sounds is needed to answer this question. Remember that the nurse starts by listening in the right lower quadrant. Review: this assessment technique . ° Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., pp. 566, 659). St. Louis: Saunders. ° Cognitive Ability: Applying ° Client Needs: Health Promotion and Maintenance ° Integrated Process: Nursing Process/Assessment ° Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0 possible points. ° 55. ID: 8482583501 Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because: It is less painful for the client Palpation and percussion can increase peristalsis Correct It identifies any potential areas of abdominal tenderness It gives the client more time to become comfortable with the examiner ° Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. The other options identify incorrect reasons for auscultating the abdomen before palpating and percussing it. ° Test-Taking Strategy: Thinking about the effects of palpating and percussing the abdomen and focusing on the subject, performing an abdominal assessment, will direct you to the correct option. Review: the procedure for an abdominal assessment. ° Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 566). St. Louis: Saunders. ° Cognitive Ability: Applying ° Client Needs: Health Promotion and Maintenance ° Integrated Process: Nursing Process/Assessment ° Content Area: Health Assessment/Physical Exam Awarded 1.0 points out of 1.0