A nurse is assessing a patient's abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?
a. Avoid palpating this patient's abdomen.
b. Document the findings in the patient's chart.
c. Have another nurse verify the findings.
d. Ask the patient when the last food intake was.
ANS: B
These findings are normal; it may take up to 30 seconds of listening to hear bowel sounds. The nurse documents the findings; no other action is needed.
You might also like to view...
An adolescent client with a sexually transmitted infection (STI) says to the nurse, "Promise you won't tell my parents about my condition." Which action by the nurse is appropriate?
A) Disclosing information to the parents B) Communicating only necessary information C) Respecting the client's privacy and confidentiality D) Honoring the client's wishes
Which is the single most important factor to consider when communicating with children?
a. Presence of the child's parent b. Child's physical condition c. Child's developmental level d. Child's nonverbal behaviors
The nurse is preparing to assess a client's blood pressure. Which artery will the nurse use for this assessment?
1. Brachial 2. Femoral 3. Radial 4. Ulnar
The early studies in LMX reported that
a. After the in-groups are formed, the vertical dyads are formed b. After the out-groups are formed, the vertical dyads are formed c. The vertical dyads form the basis for in-group and out-group formation d. The vertical dyads are independent from in-group and out-group formation