Gastrointestinal
NCLEX® practice.

Emergency Department Triage Note A 68-year-old female arrives to the emergency department with her daughter, who reports that her mother has not had a bowel movement in 8 days, has a markedly distended abdomen, and has been vomiting bile-colored fluid. The client rates her abdominal pain as 7/10. On assessment, the nurse notes high-pitched, tinkling bowel sounds in all four quadrants and tympany on percussion. Based on these findings, the nurse interprets the high-pitched tinkling bowel sounds as a sign of {{blank_1}}. The nurse anticipates that the primary health care provider will order {{blank_2}} as an initial priority intervention. The nurse should monitor the client closely for {{blank_3}}, which would indicate a worsening clinical condition.

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