2025
Meet the Client - A client on the medical surgical unit had an
abdominal hysterectomy three days ago and is now reporting
abdominal bloating, pain, and nausea. She is reluctant to eat or
drink anything stating, "The smell of food makes me nauseated."
She informs the nurse that she feels constipated and has not
passed a bowel movement since prior to surgery.
Health Promotion and Maintenance - The nurse observes the
client's abdomen is firm and distended. The nurse performs an
abdominal assessment.
In which sequence should the nurse perform the abdominal
assessment? - Inspection, auscultation, percussion, palpation.
-
Percussion and palpation can alter abdominal findings, so
inspection and auscultation are indicated prior to percussion and
palpation.
Which assessment is most important for the nurse to perform? -
Auscultate bowel sounds.
, -
The subjective data reported by the client (bloated and
nauseated) and objective data gathered by the nurse (abdomen
firm and distended) suggest that she may have decreased
peristalsis. This can be assessed by auscultation of the bowel
sounds.
Which is the most important action for the nurse to perform
when assessing bowel sounds? (Select all that apply.) - Listen
for up to 5 minutes when auscultating for bowel sounds. (The
nurse must listen for up to 5 minutes before determining what
type of bowel sounds are present.)
-
Begin auscultation in the right lower quadrant. (The nurse
should auscultate in the right lower quadrant, and then proceed
to the other quadrants.)
The nurse auscultates for the client's bowel sounds and hears
faint gurgling after 3 minutes. Which assessment finding should
the nurse document? - Hypoactive bowel sounds.
-
Normally, bowel sounds are heard 5 to 35 times per minute.
When bowel sounds are heard only after listening for 3 minutes,
they are recorded as hypoactive.