The nurse is assessing a patient's bowel sounds. After ...

[james]

The nurse is assessing a patient's bowel sounds. After auscultating each quadrant for 30 seconds, the nurse fails to hear any sounds. How should the nurse document this finding?
 
  a. Absent bowel sounds
  b. Hypoactive bowel sounds
  c. Active bowel sounds
  d. Hyperactive bowel sounds

Question 2

The nurse caring for a patient who has just had an arteriovenous (AV) access created in his right forearm. Which finding(s) is/are important for the nurse to assess? (select all that apply.)
 
  a. Presence of bruit on auscultation of the AV site
  b. Capillary refill in the left hand
  c. Blood pressure in the right arm
  d. Adequate elevation of the right arm
  e. Abdominal incision site

[lindahyatt42]

Answer to Question 1

B
Hypoactive bowel sounds can be noted in the medical record when no sounds are heard after lis-tening in each of the four quadrants for 30 seconds. For bowel sounds to be considered absent, it is necessary to verify that no sounds are heard after listening in each of the four quadrants for 5 minutes. If hyperactive, high-pitched sounds are heard in one quadrant, and decreased sounds are heard in another quadrant, assess for nausea and vomiting, as the patient may have an intestinal obstruction.

Answer to Question 2

A, B, D
The nurse should auscultate for a bruit, assess capillary refill times in both hands, and ensure that the right arm is elevated properly. The nurse should not take the patient's blood pressure in the affected (right) arm, and this procedure does not result in an abdominal incision.