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 D
Explanation
Choice A rationale:
Cool skin is not indicative of hyperglycemia. In hyperglycemia, the skin may be warm or normal.
Choice B rationale:
Shakiness is more associated with hypoglycemia (low blood glucose) rather than hyperglycemia.
Choice C rationale:
Confusion can be seen in both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
Choice D rationale:
Thirst is a common symptom of hyperglycemia. High blood glucose levels lead to increased thirst as the body tries to dilute excess glucose in the blood by drawing in more water.
Correct Answer is D
Explanation
Choice A rationale:
the nurse should hold the vial upside down and insert the needle into the center of the rubber stopper.
Choice B rationale:
Holding the syringe at a 45° angle to verify dosage is not a standard practice during the preparation of medication from a vial. The syringe should be held upright at 90° to accurately measure the desired dosage.
Choice C rationale:
Holding the syringe so that bubbles collect at the level of the plunger is incorrect. The nurse should hold the syringe so that bubbles collect at the level of the needle tip. Bubbles should be expelled from the syringe before withdrawing the medication to ensure accurate dosage.
Choice D rationale:
Injecting air into the vial with the eye of the needle immersed in the fluid is correct. This action prevents the formation of bubbles and ensures accurate dosage.
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