A client is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the client, which of the following actions should the nurse implement?
A)Assess the BP and pulse.
B)Remove the knife to assess the wound.
C)Determine the presence of Rovsing sign.
D)Insert a urinary catheter and assess for hematuria.

Question

Quizplus · Accepted Answer

The initial assessment is focused on determining whether the client has hypovolemic shock. The knife should not be removed until the client is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the client with suspected appendicitis. A client with a knife in place will be taken to surgery and assessed for bladder trauma there.

A Client Is Brought to the Emergency Department with a Knife