A nurse is assessing a client’s bowel sounds. At which of the following points in the assessment should the nurse auscultate the client’s abdomen?
A.
After palpating the abdomen
B.
Prior to percussing the abdomen
C.
Prior to inspecting the abdomen
D.
After assessing for kidney tenderness
The Correct Answer and Explanation is:
The correct answer is:
B. Prior to percussing the abdomen
Explanation:
When assessing a client’s abdomen, the order of the examination is crucial to ensure accurate findings. The four primary techniques used in abdominal assessment are inspection, auscultation, percussion, and palpation. The reason for this specific order lies in how each technique can potentially affect the others.
- Inspection: This is the first step, where the nurse visually examines the abdomen for any abnormalities such as distention, asymmetry, discoloration, or visible masses. This step provides essential baseline information and does not interfere with other assessment techniques.
- Auscultation: Auscultation is the second step and should be performed before percussion or palpation. The nurse listens to bowel sounds using a stethoscope to assess the motility of the intestines. If auscultation is done after percussion or palpation, the sounds can be altered or stimulated, leading to inaccurate findings. For example, percussion and palpation can increase bowel activity temporarily, leading to falsely heightened bowel sounds, which could mask underlying issues like an ileus or obstruction.
- Percussion: This step follows auscultation. The nurse taps on the abdomen to assess the presence of fluid, gas, or masses. Percussion can affect the frequency and intensity of bowel sounds, so it should only be performed after auscultation to avoid altering the natural state of bowel sounds.
- Palpation: Palpation is the last step in the assessment. It involves using the hands to feel for masses, tenderness, or organ enlargement. Palpation can also stimulate bowel sounds or cause discomfort to the client, which might lead to guarding or tensing of the abdominal muscles, further influencing the accuracy of the assessment.
Option A, auscultating after palpation, is incorrect because palpation can alter bowel sounds, leading to inaccurate assessments. Option C, auscultating prior to inspection, is also incorrect because inspection should always precede any other physical assessment techniques. Option D, auscultating after assessing for kidney tenderness, is incorrect because kidney tenderness is typically assessed through palpation or percussion, which could also alter bowel sounds.
In summary, auscultating the abdomen prior to percussion ensures that the nurse accurately assesses the natural state of the bowel sounds without any interference from other techniques. This approach follows the correct order of assessment: inspection, auscultation, percussion, and palpation, ensuring the most reliable data collection.