Question

After auscultating the client's bowel sounds, the nurse also listens for abdominal vascular sounds, which are soft, low-pitched, and continuous. The nurse does not hear any venous sounds.

What action should the nurse take in response to this finding?

- Stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding.
- Take the client's blood pressure and heart rate after the assessment.
- Call another nurse to verify the finding.
- Document this normal finding on the client's assessment record.

Answer 1

The nurse should document the normal finding of not hearing venous sounds in the client's assessment record, as this does not indicate an abnormality and does not require further immediate action.

Step-by-step explanation:

After auscultating a client's bowel sounds, a nurse listened for abdominal vascular sounds and did not hear any venous sounds. The appropriate action in this situation would be to document this normal finding on the client's assessment record. Abdominal vascular sounds are typically soft, low-pitched, and continuous; thus, not hearing venous sounds is normal and does not warrant immediate concern. The nurse does not need to stop the assessment, notify the healthcare provider immediately, take the client's blood pressure and heart rate, or call another nurse to verify the finding unless there are other signs of distress or abnormality.