A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
a. Auscultate for bowel sounds.
b. Notify the provider immediately.
c. Order an abdominal flat-plate x-ray.
d. Palpate the mass and measure its size.
ANS: B
This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider.
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