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A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

Apply a warm compress to the abdomen.

Administer prescribed pain medication.

Perform an abdominal assessment.

Notify the physician immediately.

Answer and Explanation

The Correct Answer is C

A. A warm compress is not appropriate for an unclear abdominal issue.

B. Pain medication should be given after determining the cause.

C. The nurse must assess before taking action to identify possible complications (e.g., bowel obstruction).

D. The physician should be notified after an assessment.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Teaching about medications. This is correct because providing education to a patient is a direct care intervention, as it involves interaction with the patient to improve their health outcomes.

B. Performing resuscitation. This is correct because resuscitation is a hands-on, immediate intervention aimed at stabilizing a patient, making it a direct care intervention.

C. Inserting a feeding tube. This is correct because placing a feeding tube is a direct intervention that involves a hands-on nursing procedure.

D. Documenting wound care. This is incorrect because documentation is an indirect care intervention. While it is essential for communication and continuity of care, it does not directly affect the patient's condition.

E. Ambulating a patient. This is correct because physically assisting a patient with walking is a direct care intervention that helps prevent complications such as deep vein thrombosis and pneumonia.

A. Risk for alteration in skin integrity B. Activity Intolerance C. Risk for Infection D. Deficient Fluid volume

Correct Answer is B

Explanation

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

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A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is B

Explanation

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