The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse?
a. Measure the client's abdominal girth.
b. Assess for abdominal guarding or rigidity.
c. Check the client's hemoglobin and hema-tocrit.
d. Ask whether the client was riding in the front or back seat of the car.
B
On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. La-boratory test results can be checked after assessment for abdominal guarding or rigidity.
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