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 C

Explanation

Choice A reason:
A registered dietitian is not appropriate as he or she can provide nutritional assessment and guidance to ensure the client's dietary needs are met.
Choice B reason:
A speech-language pathologist is not appropriate because it is crucial for addressing communication and swallowing difficulties that can arise from a stroke.
Choice C reason:
Occupational therapy is the right choice. Clients who have had a stroke often experience difficulties with activities of daily living (ADLs) due to the physical and cognitive changes that can result from the stroke. Occupational therapists are specialized in helping individuals regain or develop the skills needed to perform daily activities and tasks. They can assist stroke survivors in regaining independence in activities such as dressing, grooming, bathing, and feeding.
Choice D reason:
A physical therapist can assist with mobility and improving physical functioning, but since the question specifically mentions assistance with morning ADLs, the occupational therapist is the most appropriate choice.

A. Percuss all four quadrants of the abdomen to measure sound quality. B. Provide adequate lighting to inspect the abdomen. C. Listen to the abdominal arteries using the bell of a stethoscope. D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen. E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.

Correct Answer is B, C, E, D, A

Explanation

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort.

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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 had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?

Correct Answer is C

Explanation

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, C, E, D, A

Explanation

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