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    Hesi rn health assessment proctored exam

    After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

    Explanation & Rationale

    A. Document the presence of borborygmi. This is the best choice as loud, high-pitched gurgling indicates normal borborygmi, which are continuous bowel sounds. B. Use the bell of the stethoscope to auscultate again. The diaphragm is more suitable for bowel sounds; using the bell is unnecessary. C. Elevate the head of the client's bed immediately. Elevating the head is not indicated for assessing bowel sounds. D. Auscultate the remaining two quadrants. While thorough auscultation is important, the findings in two quadrants are sufficient to document normal bowel sounds.

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