A nurse is caring for a client diagnosed with peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Bradycardia
Hyperactive bowel sounds
Increased blood pressure
Sudden abdominal pain
The Correct Answer is D
A. Bradycardia is not typically associated with gastrointestinal perforation. Instead, tachycardia may be observed due to the body's response to a potential emergency or shock.
B. Hyperactive bowel sounds are not typically associated with gastrointestinal perforation. In fact, bowel sounds may decrease or become absent in severe cases of peritonitis or abdominal emergencies.
C. Increased blood pressure is not typically associated with gastrointestinal perforation. Hypotension may be observed due to hypovolemia resulting from fluid leakage into the peritoneal cavity.
D. Sudden abdominal pain is a key clinical manifestation of gastrointestinal perforation. The perforation of the stomach or intestines allows the contents to leak into the abdominal cavity, leading to peritonitis. Sudden and severe abdominal pain is a hallmark symptom, often described as sharp, stabbing, and constant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Positioning the client on the right side is not a standard recommendation for gastric lavage. The standard position is typically on the left side to facilitate the drainage of gastric contents.
B. Instilling 1000 mL of sterile saline is not a recommended action for gastric lavage. Gastric lavage involves the removal of stomach contents rather than instilling fluids.
C. Withdrawing fluid until it is clear is the correct action. Gastric lavage is a medical procedure used to empty the stomach contents. The process involves introducing small amounts of fluid (such as saline) into the stomach and then aspirating it back, along with gastric contents, until the aspirate is clear.
D. Connecting the NG tube to high continuous suction is not a standard approach for gastric lavage. Gastric lavage involves intermittent instillation and withdrawal of small amounts of fluid to clear the stomach.
Correct Answer is C
Explanation
A. Steatorrhea:
Steatorrhea refers to the presence of excessive fat in the stool. If a healthcare provider suspects malabsorption or fat digestion issues, they might order a fecal fat test to assess the amount of fat in the stool. This test is different from a guaiac fecal occult blood test (gFOBT), which is designed to detect blood.
B. Parasites:
The detection of parasites in the stool involves specific testing methods, such as microscopic examination of stool samples or specialized tests aimed at identifying the presence of parasitic organisms. A guaiac fecal occult blood test is not designed to detect parasites; its primary purpose is to identify occult (hidden) blood.
C. Blood:
A stool test for guaiac is specifically designed to detect the presence of occult (hidden) blood in the stool. The guaiac test involves placing a small sample of stool onto a test card containing guaiac, and a color change indicates the presence of blood. This test is commonly used to screen for gastrointestinal bleeding.
D. Bacteria:
Detecting bacteria in the stool typically involves stool cultures or specific tests designed to identify bacterial infections or imbalances in the gut microbiota. The guaiac test is not intended for detecting bacteria; its primary focus is on identifying the presence of blood in the stool.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today