Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?
Abdominal x-ray
Shifting dullness
Fluid wave
Ultrasound
The Correct Answer is D
A. Abdominal x-ray: While it can show gas or bowel obstructions, it is less effective for confirming fluid presence.
B. Shifting dullness: This physical exam technique can indicate fluid but is less accurate than ultrasound.
C. Fluid wave: This physical exam can help suggest the presence of fluid, but it is also less reliable than imaging studies.
D. Ultrasound: An ultrasound is the most accurate and non-invasive way to confirm the presence of fluid, such as ascites, in the abdomen. It provides detailed imaging and confirmation without invasive procedures.
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Correct Answer is A
Explanation
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.
Correct Answer is B
Explanation
A. Prepare an incident report for risk management: While this is necessary, it’s not the priority action as it doesn’t directly address the immediate need for type and cross-matching.
B. Inform the provider of the delay in obtaining the type and cross-match: The nurse should inform the provider first to allow for any changes to the client's preoperative plan. Immediate notification is essential for any follow-up actions, as blood products might be required, or surgery could be rescheduled if the match is not completed.
C. Obtain the client's type and cross-match: This action would be appropriate if it had not already been ordered. Since the order exists, the provider should be informed of the delay first to guide further steps.
D. Document the incident in the client's medical record: Documentation is important but should occur after informing the provider and obtaining the blood work, as it does not directly address the current client care needs.