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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Obtaining printed information about insulin self-administration is a first recommendation as it can be done after ensuring the client's ability to afford the supplies.
Choice B reason:
Making a copy of the medication reconciliation form for the client is not a first recommendation as it can be done after ensuring the client's access to supplies.
Choice C reason:
Determining whether the client can afford the insulin administration supplies is the first action to be taken. The first step should be to ensure that the client can afford the insulin administration supplies. Proper management of diabetes requires having access to the necessary equipment, including insulin, syringes, pens, or other devices. If the client cannot afford these supplies, alternative options or assistance programs may need to be explored to ensure the client's safety and well-being.
Choice D reason:
Providing the client with the contact number for a diabetes education specialist is important for long-term management, but addressing the affordability of supplies should take precedence initially.
Correct Answer is C
Explanation
Choice A reason:
ALT is not primarily used to check kidney function. Kidney function is typically assessed through other tests, such as blood urea nitrogen (BUN) and creatinine levels.
Choice B reason:
ALT is not used to assess the risk of blood clots. It is specifically related to liver function.
Choice C reason:
Alanine aminotransferase (ALT) is an enzyme found primarily in the liver. An elevated ALT level in the blood can indicate potential liver damage or disease, so the ALT test is used to assess the function of the liver.
Choice D reason:
ALT is not a test to determine heart performance. Heart function is evaluated using tests such as electrocardiograms (ECGs) or cardiac enzymes.
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