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:
This statement is objective and factual statements that do not require documentation.
Choice B rationale:
This statement is objective and factual statements that do not require documentation. Furthermore, this statement is already recorded in the medication administration record
Choice C rationale:
This statement is objective and factual statements that do not require documentation.
Choice D rationale:
The wound seems clean and does not appear to be infected. This entry by the nurse requires documentation because it is a subjective assessment of the wound condition, which may not be accurate or consistent with other observations.
Correct Answer is D
Explanation
Choice A rationale:
The client's age is not a part of the measurement in the Braden scale.
Choice B rationale:
Each element in the Braden scale has a range from one to four points, except for friction and shear, which is scored from one to three points.
Choice C rationale:
The lower the score, the higher the risk of developing pressure injuries.
Choice D rationale:
The Braden scale is a tool that helps nurses assess the risk of developing pressure injuries in clients. It consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
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