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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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:
A. Place the tourniquet below the proposed insertion site.
When preparing to insert an IV catheter, placing the tourniquet below the proposed insertion site helps facilitate venous distension, making it easier to locate and access a suitable vein for catheter insertion.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.

A. Discard the needle in a puncture-proof container. B. Remove the needle from the syringe. C. Place the needle on the bedside table. D. Recap the needle before disposal.

Correct Answer is A

Explanation

Choice A reason:
Discarding the needle in a puncture-proof container is the correct action to be taken. After administering an injection, the nurse should immediately dispose of the needle in a puncture-proof container. This helps prevent needlestick injuries and ensures proper disposal of sharp objects.
Choice B reason:
Removing the needle from the syringe is inappropriate because it could increase the risk of a needlestick injury. Needles should be discarded as a unit with the syringe.
Choice C reason:
Placing the needle on the bedside table is not a safe practice and can lead to accidental needlestick injuries.
Choice D reason:
Recapping the needle before disposal is not recommended, as it increases the risk of needlestick injuries. Many healthcare organizations discourage recapping due to the potential for accidental needle sticks. If recapping is required by local policy, it should be done using a safe method.

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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

Correct Answer is A

Explanation

Correct Answer is A

Explanation

Nurse's Notes

Vital Signs 0930:

Diagnostic Results 1030:

Company

Resources

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 preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the Injection?

Correct Answer is A

Explanation

Nurse's Notes

Vital Signs 0930:

Diagnostic Results 1030:

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