A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain.
Which of the following actions should the nurse take first?
Expose the client's abdomen to look for changes in appearance.
Determine areas of resonance across the abdomen using a systematic approach.
Use the diaphragm of a stethoscope to listen for bowel sounds.
Perform abdominal palpation by pressing gently with the finger pads.
The Correct Answer is A
After postoperative surgery, chances of infections are very high also discharges, color changes, etc.
So it is important to expose the client’s abdomen to look for changes in appearance.
Choice B is not the answer because determining areas of resonance across the abdomen using a systematic approach is not the first action that should be taken 1.
Choice C is not the answer because using the diaphragm of a stethoscope to listen for bowel sounds is not the first action that should be taken 1.
Choice D is not the answer because performing abdominal palpation by pressing gently with the finger pads is not the first action that should be taken 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
According to a study published on PubMed, it is appropriate to change alimentation tubes and feeding bags every 72 hours rather than every 24 hours.
Choice B, Aspirate residual volume every 4 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.
Choice C, Flush the tubing with 10 mL of water every 2 hr, is not necessary for continuous enteral feedings through a gastrostomy tube.
Choice D, Heat the formula to 40.5° C (105° F), is not necessary for continuous enteral feedings through a gastrostomy tube.
Correct Answer is D
Explanation
During the contemplation stage of health behavior change, the client is thinking about change and becoming motivated to get started.
The nurse should present information about the benefits of quitting smoking to help the client assess the benefits of change.
Choice A is not correct because developing a plan for the client to integrate the change into her lifestyle is more appropriate for the preparation stage.
Choice B is not correct because recommending small changes for the client to make to change her behavior over time is more appropriate for the action stage.
Choice C is not correct because assisting the client in setting goals to make the change is more appropriate for the preparation stage.
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