A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Inspection:This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation:After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation:This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary):Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort:Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds:Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression:Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

A. Requesting an order for an antiemetic may be necessary if the client continues to experience nausea, but it is not the first action the nurse should take. Before administering medication, the nurse should assess the client's vital signs and overall condition to determine the appropriate intervention.
B. While a dietitian consult may be beneficial to address the client's nutritional needs, it is not the first action the nurse should take in response to the client's symptoms of nausea and weakness. Assessing the client's vital signs and condition should be the priority.
C. Suggesting that the client rests before eating the meal may be helpful, but it does not address the underlying cause of the client's symptoms. The nurse should first assess the client's vital signs to determine the severity of the symptoms and any potential complications.
D. Checking the client's vital signs is the first action the nurse should take in response to the client's symptoms of nausea and weakness. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, can provide valuable information about the client's hemodynamic status and help identify any potential complications, such as dehydration or worsening heart failure. Based on the vital signs assessment, the nurse can then implement appropriate interventions, such as notifying the healthcare provider or providing symptomatic relief.