A patient reports gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take?
Administer morphine sulfate.
Encourage the patient to ambulate.
Offer the prescribed promethazine.
Instill a mineral oil retention enema.
The Correct Answer is B
Gas pains and abdominal distention are common postoperative complications following small bowel resection. Ambulation is a simple and effective nursing intervention that can help alleviate these symptoms. Walking helps stimulate peristalsis, which can help move gas and stool through the gastrointestinal tract. It can also help prevent postoperative complications such as pneumonia and deep vein thrombosis.
Administering morphine sulfate (option A) may relieve pain, but it can also worsen constipation and abdominal distention. Promethazine (option C) is an antiemetic medication and may be helpful if the patient is experiencing nausea, but it is not the best intervention for gas pain and abdominal distention. Instilling a mineral oil retention enema (option D) may also be helpful in some cases, but it is not typically the first intervention for these symptoms and should be ordered by a healthcare provider.
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Correct Answer is B
Explanation
The nurse should suggest the patient lie on the side, flexing the right leg². This position may help relieve pain and reduce tension in the abdominal muscles¹. Palpating the abdomen for rebound tenderness (a) may cause pain and should be avoided¹. Assisting the patient to cough and deep breathe (c) may be helpful for respiratory issues but not for abdominal pain¹. Encouraging the patient to sip clear, non-carbonated liquids (d) may be helpful for hydration but does not address the abdominal pain¹.
Correct Answer is C
Explanation
The patient's vital signs suggest that she is experiencing hypotension, tachycardia, and possibly dehydration due to acute adrenal insufficiency. The highest priority nursing intervention for this patient is to provide isotonic fluids to restore intravascular volume and blood pressure. This will also help to correct any electrolyte imbalances that may be present. Administering furosemide (Lasix) or replacing potassium losses may be necessary interventions, but they are not the highest priority at this time. Restricting sodium would be contraindicated in this situation as the patient is hypotensive and needs fluids to increase intravascular volume.
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