A nurse is assisting in the care of a client whoThe first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia.

Exhibits

Complete the following sentence by using the lists of options.

The first action the nurse should take is to

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followed by

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.

Pain level:

• Small bowel obstruction: The client reports mid-abdominal pain, which is characteristic of small bowel obstruction as the pain is often crampy and located around the abdomen.
• Acute pancreatitis: Abdominal pain is also a common symptom of acute pancreatitis, typically described as severe and persistent.

Social history:

• Small bowel obstruction: Alcohol consumption is not a typical cause of obstruction.
• Acute pancreatitis: Chronic alcohol use is a major risk factor for acute pancreatitis.

Skin findings:

• Small bowel obstruction: Skin findings are usually unaffected.
• Acute pancreatitis: In severe cases, pancreatic enzymes can leak into the skin, leading to ecchymosis (e.g., Grey Turner's or Cullen's sign). While jaundice can occur in acute pancreatitis due to bile duct obstruction, its absence does not rule out the condition.

Lipase level:

• Small bowel obstruction: Lipase is generally normal.
• Acute pancreatitis: Elevated lipase levels are highly indicative of acute pancreatitis.

WBC count:

• Small bowel obstruction: A mild increase in WBC may occur due to bowel distension. The client’s WBC count is 9,000/mm³, which is within the normal range.
• Acute pancreatitis: WBC levels are often elevated due to inflammation.

Abdominal findings:

• Small bowel obstruction: Tenderness and high-pitched bowel sounds are typical signs.
• Acute pancreatitis: Abdominal tenderness can also be present in acute pancreatitis, but high-pitched bowel sounds are more specific to small bowel obstruction.

A. Apply five drops of developer to each smear: Typically, two drops of developer are applied per sample, not five. Applying excess developer may dilute the reaction and yield unreliable results.
B. Use the same part of stool for each sample: Samples should be taken from different parts of the stool to ensure accuracy and detect localized bleeding.
C. Ensure the sample contains no urine: Urine contamination can interfere with test results, leading to inaccurate findings. The client should collect a clean stool sample.
D. Wait 10 min before applying the developing solution: The developing solution should be applied immediately after placing the stool sample on the test card to prevent errors in interpretation.