Nokea
During a morning assessment, the nurse observes that a patient displays bulging flanks when supine with the knees flexeWhich action should the nurse take next?
Correct Answer: A
Rationale: The correct answer is A: Measure the patient's abdominal girth. Bulging flanks could indicate ascites, which is an abnormal accumulation of fluid in the abdominal cavity. Measuring the abdominal girth can help assess for the presence and severity of ascites. This step is important for further evaluation and monitoring of the patient's condition. Auscultating the abdomen for 5 minutes (choice B) would not address the potential underlying issue of ascites. Simply documenting the finding (choice C) without further assessment could delay necessary interventions. Notifying the charge nurse (choice D) is premature without completing a thorough assessment first.