问题
单项选择题
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nause
a. What should the nurse do firstA. Auscultate for bowel sounds.B. Palpate the abdomen.C. Change the client’s position.D. Insert a rectal tub
答案
参考答案：A
解析：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. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won’t relieve the client’s discomfort.