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 D
Explanation
Choice A reason:
Attaching the drainage bag to the side rails of the bed can create tension on the catheter and increase the risk of trauma or dislodgment.
Choice B reason:
Emptying the drainage bag when it is three-quarters full is appropriate to prevent the bag from becoming too heavy and pulling on the catheter. However, this is a practice for maintaining bag weight, not part of the overall care plan.
Choice C reason:
Taping the catheter to the lower abdomen is not recommended. Taping the catheter can cause irritation, tension, and skin breakdown, increasing the risk of infection and trauma to the urethra. The catheter should be secured to the thigh using a catheter securement device if necessary.
Choice D reason:
Keeping the drainage bag below the level of the bladder is the correct recommendation. When caring for a client with an indwelling urinary catheter, it is important to maintain proper catheter and drainage bag positioning to prevent complications. Keeping the drainage bag below the level of the bladder helps promote the free flow of urine, prevent reflux of urine into the bladder, and minimize the risk of urinary tract infections.
Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]
No explanation
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