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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?

A) Assessment of the client's vital signs.
B) Document the finding as the only action.
C) Determine the time the client last voided.
D) Insert a rectal tube for the passage of flatus.

Answer :

Final answer:

The priority nursing action in a post-operative client presenting with abdominal distention following inguinal herniorrhaphy should be to determine the time the client last voided. It's important due to the possibility of urinary retention, a common post-surgical complication.

Explanation:

In the case of a male client who had an inguinal herniorrhaphy a few hours ago and now presents with a distended lower abdomen and dullness to percussion, the priority nursing action should be C) Determine the time the client last voided. This assessment is critical because urinary retention, which may cause the symptoms described, is a common post-operative complication, particularly after surgeries involving the lower body. The inability to void can cause bladder distention and manifest as abdominal distention and discomfort. The use of a rectal tube may not be appropriate unless there are other signs of bowel obstruction or compromise.

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