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 C
Explanation
A.When mixing insulins, you should draw the short-acting insulin into the syringe first. This is done after injecting air into both vials (first into intermediate-acting, then into short-acting). Drawing intermediate-acting insulin first can contaminate the short-acting insulin vial with the longer-acting solution, which could alter the effectiveness of future doses.
B.Although this step is required when mixing insulins, it is not the first step. The nurse should first inject air into both vials to maintain vial pressure.
C.The nurse should inject air into the intermediate-acting insulin vial first because it helps prevent contamination and maintains the correct pressure within the vial. Intermediate-acting insulin, typically NPH (Neutral Protamine Hagedorn), is cloudy, and air injection into the vial allows for easy withdrawal later on without disrupting the order of mixing.
D.Injecting air into the short-acting insulin vial is necessary but should be done after injecting air into the intermediate-acting vial. By injecting air into both vials first, the nurse prevents a vacuum effect, which can make it difficult to draw up the insulin. After injecting air, the nurse can draw the short-acting insulin into the syringe before moving to the intermediate-acting insulin. This order minimizes the risk of contamination.
Correct Answer is C
Explanation
If a client expresses confusion or lack of understanding about a medical procedure, the nurse should notify the provider so that they can clarify any misunderstandings and ensure that the client is fully informed before giving their consent.
Choice A is wrong because providing brochures about the procedure may not be sufficient to address the client’s confusion or lack of understanding.
Choice B is wrong because completing an incident report is not an appropriate action in this situation.
Choice D is wrong because it is the provider’s responsibility to ensure that the client fully understands the procedure and gives informed consent.
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