The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse?
1. Percuss for flatness over the liver.
2. Palpate for bladder fullness.
3. Use the p.r.n. order to medicate the client with an antacid.
4. Inspect the sacral area for edema.
Correct Answer: 2
Rationale 1: Flatness is the normal percussion sound over the liver.
Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort.
Rationale 3: The nurse should not medicate the client until assessment is complete.
Rationale 4: Sacral edema may occur with the bed-bound client, but should not be a contributor to abdominal pain.
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