A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Determine areas of resonance across the abdomen using a systematic approach.
Use the diaphragm of a stethoscope to listen for bowel sounds.
Expose the client's abdomen to look for changes in appearance.
Perform abdominal palpation by pressing gently with the finger pads.
The Correct Answer is C
Choice A rationale:
Determining areas of resonance across the abdomen can help evaluate for gas accumulation, but it is not as sensitive as visual inspection.
Choice B rationale:
Listening for bowel sounds can help assess for bowel function, but it is not reliable in detecting complications.
Choice C rationale:
The nurse should first expose the client's abdomen to look for changes in appearance. This is because sudden, severe abdominal pain after bowel resection could indicate a complication such as anastomotic leak, bowel perforation, or internal bleeding. These conditions can cause signs of peritonitis, such as abdominal distension, rigidity, or bruising. By visually inspecting the abdomen, the nurse can quickly assess for these signs and initiate appropriate interventions.
Choice D rationale:
Performing abdominal palpation can help identify areas of tenderness or masses, but it can also cause pain and discomfort to the client and increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A) False imprisonment: This choice is incorrect because false imprisonment involves unlawfully restricting another person's freedom of movement. In this scenario, the AP has not acted to physically restrict the client's movement but has threatened to do so.
- B) Assault: This is the correct answer. Assault in the context of tort law refers to an act that creates an apprehension in another of an imminent, harmful, or offensive contact. The AP's threat to use restraints if the client does not stay in bed constitutes assault because it puts the client in immediate fear of being physically restrained.
- C) Defamation of character: This choice is incorrect because defamation involves making a false statement that injures a person's reputation. The AP's statement does not concern the client's reputation but rather threatens a physical action.
- D) Battery: This choice is incorrect. Battery involves actual offensive or harmful physical contact. Since the AP has not made any contact but has only threatened it, battery has not occurred.
Correct Answer is D
Explanation
Choice A rationale:
Room number is not a specific client identifier and does not ensure accurate identification.
Choice B rationale:
Age is not a unique identifier and may not differentiate between clients with the same age.
Choice C rationale:
Bed number alone is not sufficient for accurate client identification.
Choice D rationale:
A photograph is a reliable client identifier and ensures accurate identification before administering medication or performing procedures.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.