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?

Perform abdominal palpation by pressing gently with the finger pads.

Determine areas of resonance across the abdomen using a systematic approach.

Expose the client's abdomen to look for changes in appearance.

Use the diaphragm of a stethoscope to listen for bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Palpation can help assess for tenderness, rigidity, or masses in the abdomen, which might indicate infection, bleeding, or other complications. However, palpation could potentially worsen a condition such as an evisceration or dehiscence, or cause additional pain. Therefore, palpation should be done only after the visual inspection and with great caution in the presence of severe pain.
Choice B reason:
Percussion is useful for assessing the presence of gas, fluid, or solid masses in the abdomen. Resonance might indicate normal air-filled intestines, while dullness could suggest fluid or mass. However, percussion is not the first action in an acute setting of sudden severe pain because it does not provide immediate information that could be life-saving. It is a later step in the physical examination.
Choice C reason:
Visual inspection is the first step because it can quickly reveal critical signs such as swelling, distention, redness, or evidence of wound complications like dehiscence or evisceration. Identifying these signs early allows for rapid intervention, which could be life-saving. This is why exposing and inspecting the abdomen is the priority in the context of sudden severe pain following surgery.
Choice D reason:
Listening for bowel sounds can provide information about the function of the gastrointestinal system. Absence of bowel sounds might suggest a paralytic ileus, while hyperactive sounds could indicate a bowel obstruction. However, in the context of sudden, severe abdominal pain postoperatively, auscultation is not the first priority.

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Correct Answer is A

Explanation

Choice A reason:
Plain yogurt is appropriate for a full-liquid diet as it is a liquid at room temperature and provides nutritional value.
A full-liquid diet consists of foods that are liquid at room temperature and can be easily poured or sipped. It includes clear liquids as well as liquids that are more opaque, like milk-based products and certain blended foods. Among the options provided:
Choice B reason:
Scrambled eggs are not appropriate. Scrambled eggs are not typically considered a part of a full-liquid diet. They have a solid texture and may not be suitable for this specific dietary progression.
Choice C reason:
Oatmeal is inappropriate. Oatmeal is a solid food that does not meet the criteria for a full-liquid diet. It is usually allowed on a soft or regular diet after appropriate postoperative recovery.
Choice D reason:
Applesauce is inappropriate. While applesauce is softer than solid foods, it is not typically included in a full liquid diet. It is more commonly associated with a soft or pureed diet.

A. "New dressing applied as prescribed; no drainage on old dressing." B. "Client premedicated with MSO, sub prior to dressing change." C. "The wound seems clean and does not appear to be infected." D. "No changes noted to the wound from previous nursing notes."

Correct Answer is A

Explanation

Choice A reason:
"New dressing applied as prescribed; no drainage on old dressing. “This entry provides clear and concise information about the action taken (applying a new dressing as prescribed) and the assessment of the old dressing (no drainage present). It accurately reflects the dressing change process and the status of the wound.
Choice B reason:
"Client premedicated with MSO, sub-prior to dressing change." This entry is incorrect because it provides information about the client being premedicated, but it doesn't specifically address the dressing change or the pressure injury.
Choice C reason:
"The wound seems clean and does not appear to be infected." While this entry provides an assessment of the wound's cleanliness and potential infection, it lacks specific details about the dressing change itself.
Choice D reason:
"No changes noted to the wound from previous nursing notes." This entry focuses on comparing the wound to previous notes but doesn't provide information about the current dressing change or assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet?

Correct Answer is A

Explanation

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

Correct Answer is A

Explanation

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