A patient recovering from a colonoscopy reports abdominal pain of 4 on a 5 point scale. The patient's abdomen is rigid and vital signs are T 99.2, HR 94, R 28, and BP 98/69. What initial action by the nurse is indicated?
1. Assist the patient to turn to aid in relieving the flatus buildup.
2. Continue to observe the patient for additional changes in 15 minutes.
3. Notify the physician.
4. Medicate the patient for discomfort.
3
Rationale 1: The patient may experience flatus after a colonoscopy but this would not cause abdominal rigidity or cause pain to be rated 4 on a 5 point scale.
Rationale 2: Taking no action is negligent of the nurse. These findings indicate there is a complication present that needs immediate intervention.
Rationale 3: The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the physician.
Rationale 4: Medication for pain may be necessary but the priority action is notification of the physician.
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