MSNCB Medical-Surgical Nursing Exam Prep

Category - Medical Surgical

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Forty-eight hours after a nephrectomy, a client complains of increasing nausea and abdominal pressure. The nurse's first nursing action is to:

Change the client's position to relieve abdominal pressure
Auscultate bowel sounds
Insert a rectal tube to relieve flatus
Administer morphine SO₄, 6 mg, as ordered for the relief of discomfort

Explanation

Answer: B - Auscultate bowel sounds. Though nausea may occur following the administration of narcotics, if it is accompanied by the absence of bowel sounds and upper abdominal distention, gastric or small-intestine dilation should be suspected and the nurse's findings reported to the physician.

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