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The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?

Option 1: Assess the client's vital signs.
Option 2: Determine the time the client last voided.
Option 3: Document the finding as the only action.
Option 4: Insert a rectal tube for the passage of flatus.

Answer :

Final answer:

The priority nursing action is to insert a rectal tube for the passage of flatus.

Explanation:

The priority nursing action for a male client who had an inguinal herniorrhaphy and is experiencing a distended lower abdomen with dullness to percussion is to insert a rectal tube for the passage of flatus (Option 4). This helps relieve the accumulation of gas in the intestines and reduces the risk of further complications. The nurse should also assess the client's vital signs (Option 1) to monitor for any signs of distress or instability. Determining the time the client last voided (Option 2) is important, but it is not the priority action in this situation.

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