A client presents to the emergency department vomiting dark brown emesis and in severe abdominal pain. The client reports to the nurse of recently being diagnosed with adenocarcinoma of the small intestine. After auscultating bowel sounds and obtaining vital signs, which prescription should the nurse implement next?
Insert a nasogastric tube (NGT) and attach to low intermittent suction.
Place an indwelling urinary catheter and attach a bedside drainage unit.
Send the client to x-ray for a flat plate of the abdomen.
Give a prescribed analgesic for temperature above 101°F (38.3°C).
The Correct Answer is A
A. Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction would be appropriate in this situation. Dark brown emesis could indicate gastrointestinal bleeding, which may require gastric decompression to prevent further vomiting and assess the volume and characteristics of the gastric contents.
B. Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the priority intervention in this scenario.
C. Sending the client to x-ray for a flat plate of the abdomen may provide diagnostic information, but it is not the most immediate intervention needed in this situation.
D. Giving a prescribed analgesic for a temperature above 101°F (38.3°C) is not the priority intervention in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Preventing esophageal reflux is essential in managing symptoms associated with a direct hiatal hernia. Nursing interventions may include promoting proper positioning (elevating the head of the bed), encouraging smaller, more frequent meals, avoiding trigger foods, and administering medications as prescribed to reduce acid reflux.
B Promoting intestinal peristalsis may be beneficial in certain gastrointestinal conditions, such as constipation but it is not directly related to the management of a direct hiatal hernia.
C Promoting effective swallowing is important for overall swallowing function and preventing aspiration in some cases, it may not directly address the symptoms or complications associated with a direct hiatal hernia.
D Maintaining intact oral mucosa is important for oral health and preventing complications such as oral mucositis, but it is not directly related to the management of a direct hiatal hernia.
Correct Answer is A
Explanation
A. Increasing oral fluid intake can help thin respiratory secretions, making them easier to expectorate. This can be particularly beneficial for a client experiencing thickened, tenacious mucous associated with asthma and bronchitis.
B. Avoiding crowded enclosed areas can reduce the risk of exposure to respiratory pathogens but it may not directly address the client's current symptoms of shortness of breath and productive cough.
C. Monitoring medication side effects does not directly address the client's current symptoms of shortness of breath and productive cough.
D. Addressing anxiety is important for overall well-being but it may not directly address the underlying respiratory symptoms or promote effective airway clearance.
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