34. If a client's bowel sounds are absent, a nurse should listen for at least:
Test-Taking Tip
Is it "seconds" or "minutes"? An accurate assessment takes time.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is incorrect because all four quadrants should be assessed and normal bowel sounds may not occur more often than every 20 seconds, requiring a minimum of 1 minute and 20 seconds. Answer 2 is incorrect because all four quadrants should be assessed and normal bowel sounds may not occur more often than every 20 seconds requiring, a minimum of 1 minute and 20 seconds. Answer 3 is incorrect because, to determine if bowel sounds are absent, the nurse must listen for a minimum of 3 minutes and for as long as 5 minutes. Answer 4 is correct because, to determine if bowel sounds are absent, the nurse must listen for a minimum of 3 minutes and for as long as 5 minutes.
