The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority?
a. Provide oral care after each episode of emesis.
b. Apply a skin barrier to the patient's perineal area. c.
Check the patient to see if he has a fecal impaction.
d. Administer antiemetic medication with a sip of water.
ANS: C
The patient who has abdominal pain and frequent small stools should be checked for fecal impaction, especially since the patient is vomiting. Immobility is a risk factor for the development of fecal impaction. The other actions can be performed once fecal impaction is ruled out.
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