A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?
Explanation & Rationale
A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in): Palpation assesses tenderness, masses, or organ enlargement but does not evaluate peristalsis. Palpating too soon postoperatively can also cause discomfort or disrupt healing. B. Auscultate each of the four quadrants for 5 min before determining sounds are absent: Bowel sounds indicate peristalsis, and a full 5 minutes of auscultation is required before concluding they are absent, especially after abdominal surgery where bowel activity may be reduced. C. Percuss each of the four quadrants of the abdomen: Percussion evaluates the presence of fluid, gas, or organ borders but does not provide information about bowel motility. It is useful for assessing distention but not peristalsis. D. Inspect each of the four quadrants for abdominal distention: Inspection identifies visible abnormalities such as distention, scars, or pulsations. While distention may suggest reduced peristalsis, visual inspection alone does not confirm bowel activity.