A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.
Correct Answer: A. Auscultate bowel sounds.
If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician.
Option B: Palpation is the examination of the abdomen for crepitus of the abdominal wall, for any abdominal tenderness, or for abdominal masses. It may be used to assess the client but this will not be the first choice following a nephrectomy.
Option C: Changing positions would not diminish the client’s nausea and abdominal pressure.
Option D: If peristalsis is absent, inserting a rectal tube won’t relieve the client’s discomfort.