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 Reason:
Percussion is useful for assessing the presence of gas, fluid, or solid masses in the abdomen. Resonance might indicate normal air-filled intestines, while dullness could suggest fluid or mass. However, percussion is not the first action in an acute setting of sudden severe pain because it does not provide immediate information that could be life-saving. It is a later step in the physical examination.
Choice B Reason:
Using the diaphragm of a stethoscope to listen for bowel sounds: Absence of bowel sounds might suggest a paralytic ileus, while hyperactive sounds could indicate a bowel obstruction. However, in the context of sudden, severe abdominal pain postoperatively, auscultation is not the first priority.
Choice C Reason:
Visual inspection is the first step because it can quickly reveal critical signs such as swelling, distention, redness, or evidence of wound complications like dehiscence or evisceration. Identifying these signs early allows for rapid intervention, which could be life-saving. This is why exposing and inspecting the abdomen is the priority in the context of sudden severe pain following surgery.
Choice D Reason:
Palpation can help assess for tenderness, rigidity, or masses in the abdomen, which might indicate infection, bleeding, or other complications. However, palpation could potentially worsen a condition such as an evisceration or dehiscence, or cause additional pain. Therefore, palpation should be done only after the visual inspection and with great caution in the presence of severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Perform percussion over the lower back. Percussion is typically performed over the lung segments being drained, and it is commonly done with cupped hands to promote loosening and mobilization of mucus in the airways. In the case of cystic fibrosis, this procedure is typically done on the back to help clear mucus from the lungs.
Choice B Reason:
Cover the area of percussion with a towel. Placing a towel or cloth over the area of percussion helps to protect the skin and provide some comfort for the client during the procedure.
Choice CReason:
Schedule postural drainage after meals. Postural drainage is typically scheduled at times when the client is less likely to have a full stomach, as it can be uncomfortable and lead to nausea if performed immediately after meals. It's important to provide the client with time to digest before the procedure.
Choice DReason:
Instruct the client to exhale quickly during vibration. Vibration is often performed by having the client exhale quickly while the nurse applies gentle oscillations to the chest wall. This helps dislodge mucus and facilitate its removal.
Correct Answer is B
Explanation
Choice A Reason:
Calcium 9.6 mg/dL - Within the normal range (usually around 8.5-10.5 mg/dL).
Choice B Reason:
Potassium 5.8 mEq/L. A potassium level of 5.8 mEq/L is higher than the normal range (usually around 3.5-5.0 mEq/L). Hyperkalemia, or elevated potassium levels, can be a serious condition that can lead to cardiac arrhythmias and other complications. The provider needs to be informed so that appropriate interventions can be initiated.
Choice C Reason:
Magnesium 1.9 mEq/L - While this is slightly below the lower end of the normal range (usually around 1.5-2.5 mEq/L), it is not typically considered critically low, and the provider's response would depend on the client's clinical condition.
Choice D Reason:
Sodium 140 mEq/L - Within the normal range (usually around 135-145 mEq/L).
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