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.
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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Related Questions
Correct Answer is C
Explanation
A. Nurse’s lounge. This is incorrect because the nurse’s lounge is not a private or appropriate setting for a report. It may not be secure, and other personnel who are not directly involved in the client’s care may overhear confidential information, which violates privacy regulations such as HIPAA.
B. Conference area. This is incorrect because, while a conference room provides some privacy, bedside reporting is preferred as it allows for direct patient involvement, immediate clarification, and continuity of care.
C. Client’s bedside. This is correct because bedside reporting enhances communication, ensures the oncoming nurse can visually assess the client, and allows the client to participate in their care. This approach promotes safety and reduces the risk of errors during the handoff.
D. Outside client’s room. This is incorrect because it does not ensure privacy and may not allow for direct verification of client information. Discussing a report outside the room could also expose confidential information to unintended listeners.
Correct Answer is A
Explanation
A. Before assisting a patient, especially one with mobility concerns, the nurse must verify provider orders to determine any restrictions or special considerations.
B. Administering pain medication before knowing activity restrictions could lead to falls or complications.
C. While assistance may be needed, the first priority is to check the patient's activity orders to determine the safest way to proceed.
D. Providing a walker might help, but the nurse must first confirm whether assistive devices are appropriate for the patient.
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