Examkin

Question

Difficulty: MediumTechniques of Physical Assessment

A nurse is preparing to perform an abdominal assessment on a client who is receiving continuous nasogastric (NG) tube suctioning for a bowel obstruction. Which action should the nurse take to ensure an accurate physical assessment?

  1. Temporarily turn off the nasogastric tube suction before auscultating for bowel sounds.Answer
  2. B
    Palpate the abdomen for rigidity and tenderness prior to auscultating the four quadrants.
  3. C
    Auscultate the client's abdomen using the bell of the stethoscope to detect high-pitched bowel sounds.
  4. D
    Delegate the routine auscultation of the client's bowel sounds to the unlicensed assistive personnel (UAP).

Answer

Temporarily turn off the nasogastric tube suction before auscultating for bowel sounds.
When assessing the abdomen of a client with an active nasogastric tube connected to suction, the nurse must temporarily turn off the suction before auscultation. If the suction is left on, the sound of the stomach contents and air moving through the tube can mimic normal or hyperactive bowel sounds, making it impossible to accurately assess the client's true gastrointestinal status.

Step-by-Step Solution

1
Identify the standard sequence for an abdominal assessment.
The correct sequence is inspect, auscultate, percuss, and palpate.
Performing palpation or percussion before auscultation can alter natural bowel activity.
2
Consider the impact of the client's continuous NG tube suctioning.
The mechanical sound of the suction device can be transmitted through the abdominal wall.
Suction noises can easily be mistaken for hyperactive bowel sounds or obscure hypoactive sounds.
3
Determine the correct nursing intervention for accurate auscultation.
The suction must be temporarily paused while listening with the diaphragm of the stethoscope.
This isolates the client's physiological sounds from the mechanical equipment.

Key Concept

Abdominal Assessment Techniques and Sequence
Rate this question

Topics

Techniques of Physical Assessment

More questions from this topic