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 B
Explanation
“Contract your pelvic muscle when performing the exercises.” Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum.
To do Kegels correctly, you need to contract and relax your pelvic floor muscles.
Choice A is wrong because you should avoid holding your breath while doing Kegel exercises.
Instead, breathe freely during the exercises.
Choice C is wrong because you should focus on tightening only your pelvic floor muscles and be careful not to flex the muscles in your buttocks.
Choice D is wrong because it takes time to strengthen pelvic floor muscles.
You should aim for at least three sets of 10 to 15 repetitions a day and give it 3 to 6 weeks before expecting improvement12.
Correct Answer is B
Explanation
This is the nurse’s priority intervention for a client undergoing a total laryngectomy because it is important for the client to understand how to use an artificial larynx to communicate after the surgery.
Choice A is wrong because explaining the techniques of esophageal speech is not the priority intervention for a client undergoing a total laryngectomy.
Choice C is wrong because determining the client’s reading ability is not the priority intervention for a client undergoing a total laryngectomy.
Choice D is wrong because scheduling a support session for the client is not the priority intervention for a client undergoing a total laryngectomy.
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