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 D
Explanation
In general, parental (or legal guardian) consent is required for any diagnostic or surgical procedure performed on a child under the age of 181.
Choice A is wrong because the mother’s 21-year-old sibling is not a parent or legal guardian of the infant.
Choice B is wrong because the infant’s provider cannot sign the consent form on behalf of the infant.
Choice C is wrong because the infant’s grandparent cannot sign the consent form unless they are a legal guardian of the infant.
Correct Answer is C
Explanation
“I should limit the time that I spend sitting in a chair.” This is important because sitting for long periods of time can increase the risk of thrombus formation.
Choice A is wrong because crossing the legs while sitting can impede blood flow and increase the risk of thrombus formation.
Choice B is wrong because leg exercises should be performed more frequently than once every 4 hours while awake.
Choice D is wrong because massaging the legs when they hurt can dislodge a thrombus and cause it to travel to other parts of the body.
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