A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

Choice A rationale:

Inserting a glycerin suppository involves a sterile procedure, and it is typically performed by licensed nursing personnel, not assistive personnel.

Choice B rationale:

Assisting with ambulation for a client with a pulmonary infection is within the scope of practice for assistive personnel. They can help with mobility and activities of daily living.

Choice C rationale:

Irrigating a client's infected surgical wound requires skill and knowledge to prevent infection and promote healing. This task is typically performed by licensed nursing personnel.

Choice D rationale:

Showing a client how to use an incentive spirometer involves education and is best done by licensed nursing personnel.

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.