Several hours after an endoscopic procedure, a patient develops severe abdominal pain, a rigid abdomen, and increasing pulse rate. What should the nurse do first?
Correct answer: A. Keep the patient nil by mouth and request urgent medical review
- A. Keep the patient nil by mouth and request urgent medical review
- B. Offer a meal to determine whether the pain is related to hunger
- C. Apply a warm pack and reassess the abdomen in one hour
- D. Administer an oral laxative to relieve possible constipation
Explanation
Severe pain, rigidity, and tachycardia after an invasive procedure may indicate perforation and peritonitis. Keeping the patient nil by mouth and obtaining urgent review reduces further risk and supports emergency management.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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