A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area
Which action should the nurse take?
a.
Assess the client's heart rate and blood pressure.
b.
Determine when the client last voided.
c.
Ask if the client is experiencing flatus.
d.
Auscultate all quadrants of the client's abdomen.
ANS: B
Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy.
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