Care Manager Certification Practice Exam

During an observation of a nurse auscultating bowel sounds, which action requires intervention by the charge nurse?

1. Clamps the NG tube during auscultation.

2. Performs auscultation between meals.

3. Auscultates bowel sounds for 3 to 5 minutes.

4. Palpates the abdomen prior to performing auscultation.

The correct answer is: Palpates the abdomen prior to performing auscultation.

In this scenario, the correct answer highlights that palpating the abdomen before auscultating bowel sounds is an action that requires intervention. This is because palpation can alter or change the sound of bowel activity. When a nurse palpates the abdomen, it can stimulate bowel activity, potentially leading to more pronounced or altered sounds, which may not accurately reflect the patient's normal condition. Auscultation is ideally performed without prior manipulation of the abdomen to achieve a true assessment of bowel function. The other actions do not necessitate intervention. Clamping the NG tube during auscultation might temporarily prevent air and fluid passage, but it is not a standard practice that typically infringes on any protocol as long as it does not cause distress to the patient. Performing auscultation between meals is appropriate because it ensures the stomach and intestines are relatively quiet, allowing for a clearer assessment of bowel sounds. Lastly, auscultating bowel sounds for 3 to 5 minutes is within the guidelines for thorough examination, offering enough time to detect any abnormalities in bowel activity.