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 C
Explanation
Choice A rationale:
Ensuring the gloves in the surgical suite are powdered is not appropriate, as latex gloves with powder can aerosolize latex proteins, increasing the risk of an allergic reaction. Powder-free gloves should be used.
Choice B rationale:
Cleaning stoppers with povidone-iodine is not directly related to latex allergy and may not be necessary in the context of latex allergy.
Choice C rationale:
Scheduling the client as the first surgical procedure of the day is appropriate to minimize the client's exposure to latex in the environment.
Choice D rationale:
Removing stopcocks from IV tubing is not a standard precaution for latex allergy and may not be necessary in all cases. Minimizing latex exposure in the surgical suite is a more comprehensive approach.
Correct Answer is D
Explanation
Choice A rationale:
Applesauce is not typically considered a full liquid. It has a thicker consistency, and full liquid diets usually include clear liquids and foods that are liquid at room temperature.
Choice B rationale:
Oatmeal is not part of a full liquid diet. It has a solid consistency and is not in a liquid or semi-liquid form.
Choice C rationale:
Scrambled eggs are not included in a full liquid diet. They are a solid food and are not in a liquid or semi-liquid form.
Choice D rationale:
Plain yogurt is appropriate for a full liquid diet. It meets the criteria of being in a liquid or semi-liquid form at room or body temperature.
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