Question

A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a 0 to 10 scale. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first?

a) Administer antiemetic medication.

b) Reassure the client that pain is expected postoperatively.

c) Document the findings in the client's chart.

d) Prepare the client for a stat abdominal X-ray.

Answer 1

The nurse should prioritize the client's immediate needs due to postoperative complications and prepare them for a stat abdominal X-ray for prompt diagnosis and treatment.

Step-by-step explanation:

The nurse is attending to a client who is 2 days postoperative following a cholecystectomy and is presenting with symptoms including being nauseous for more than 24 hours, high pain levels, a hard and distended abdomen, and absent bowel sounds. In this scenario, the nurse, after consulting with the healthcare provider, should prioritize the client's immediate needs and prepare them for a stat abdominal X-ray. This is because the symptoms indicate a possible complication, such as a bowel obstruction or an ileus, which needs to be identified and treated promptly. Administering antiemetic medication, reassuring the client, or documenting the findings, while important, do not take precedence over diagnostic procedures in this case. The abdominal X-ray is crucial for diagnosis and determining the next steps in care.