During a morning assessment,the nurse observes that a patient displays bulging flanks when supine with the knees flexed.Which action should the nurse take next?

Question

Quizplus · Accepted Answer

The nurse's initial assessment indicates fluid accumulation.The nurse needs to obtain more information,first measuring abdominal girth.The nurse can then percuss from the umbilicus to the flanks to detect fluid shifts,and document all findings.The nurse will only auscultate bowel sounds for 5 minutes in each quadrant if bowel sounds are not heard before then.It is unnecessary to notify the charge nurse at this time.

During a Morning Assessment,the Nurse Observes That a Patient Displays