HESI Health Assessment WGU d344 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. Borborygmi are loud, high-pitched, and continuous gurgling sounds, often associated with hyperactive bowel activity. Documenting this finding is appropriate. B. While auscultating all four quadrants is a standard practice, the finding of borborygmi in two quadrants suggests significant activity, making further immediate auscultation unnecessary unless other symptoms suggest a different pathology. C. Elevating the head of the bed may provide comfort but is not required based on the findings of bowel sounds alone. D. The diaphragm, not the bell, is the appropriate part of the stethoscope for auscultating bowel sounds due to their higher pitch.
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