The Nurse Is Performing a Physical Assessment for a Client

question 14

Multiple Choice

The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day.The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area.Which is the nurse's priority action?

• A) Assess the client's vital signs.
• B) Determine the last time the client voided.
• C) Insert a rectal tube to facilitate passage of flatus.
• D) Document the findings in the client's chart.

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