A nurse is assigned to care for a 68-year-old adult client who had a right total hip arthroplasty (THA) 2 days ago on the medical-surgical unit. During shift assessment, the nurse documents new onset of symptoms including chest pain and dyspnea. Computed tomography pulmonary angiography (CTPA) confirmed the diagnosis of a sub-massive PE. The orthopedic surgeon enters orders. The nurse revises the plan of care for the client with confirmed diagnosis of PE.
Click or place an X to specify nursing actions that are indicated (appropriate or necessary) and those that are contraindicated (not useful and could be harmful) related to drug therapy for this client.

Pyloric obstruction involves a mechanical blockage at the stomach outlet, leading to the accumulation of gastric contents. Knowledge of gastrointestinal decompression and the therapeutic purpose of nasogastric tubes in managing increased intragastric pressure and preventing emesis is required here.

Choice A rationale

Pyloric obstruction causes gastric stasis and distension because contents cannot enter the duodenum. Nasogastric intubation provides decompression by removing accumulated secretions and gas, which relieves pressure, prevents vomiting, and reduces the risk of aspiration in the client.

Choice B rationale

Providing nutrition via tube feeding is contraindicated in pyloric obstruction. Because the outlet of the stomach is blocked, any enteral formula introduced would accumulate in the stomach, worsening distension and significantly increasing the risk of reflux or aspiration.

Choice C rationale

While gastric pH can be measured via a nasogastric tube, it is not the primary therapeutic rationale for tube placement in a client with a mechanical obstruction. Decompression is a critical intervention to ensure safety and comfort.

Choice D rationale

Administering oral medications through a nasogastric tube is ineffective during an obstruction. The medication cannot pass the pylorus to be absorbed in the small intestine, and it adds volume to an already overfilled and pressurized stomach.

Dexamethasone is a potent corticosteroid used to reduce cerebral edema in brain tumor patients. Prioritizing care requires identifying life-threatening neurological changes or severe medication side effects, applying knowledge of intracranial pressure, glucose metabolism, and the hierarchy of clinical needs.

Choice A rationale

Acute loss of orientation to self indicates a significant decline in neurological status or increased intracranial pressure. This is a medical emergency requiring immediate intervention to prevent brain herniation, outweighing stable physical side effects of steroid therapy.

Choice B rationale

Weight gain is a common side effect of long-term dexamethasone use due to fluid retention and increased appetite. While it requires monitoring, it is an expected systemic effect and does not represent an immediate life-threatening crisis.

Choice C rationale

Insomnia is a known side effect of corticosteroids because they can interfere with the circadian rhythm and stimulate the central nervous system. It affects the client's comfort but does not indicate immediate physiological or neurological compromise.

Choice D rationale

Glucocorticoids cause hyperglycemia; 350 mg/dL is high compared to the normal fasting range of 70 to 100 mg/dL. While it requires insulin or dosage adjustment, it is less urgent than an acute neurological deficit..