A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 ml. In the past 6 hr. The nurse should monitor the client for which of the following electrolyte Imbalances?

Decreased potassium level

Decreased calcium level

Elevated magnesium level

Elevated sodium level

Answer and Explanation

The Correct Answer is A

A. Decreased potassium level
NG tube drainage can lead to hypokalemia (low potassium levels) due to the loss of gastric fluids, which contain significant amounts of potassium. This choice is correct.

B. Decreased calcium level
Calcium levels are not directly affected by NG tube drainage.

C. Elevated magnesium level
NG tube drainage does not typically lead to elevated magnesium levels.

D. Elevated sodium level
NG tube drainage can result in hyponatremia (low sodium levels) due to the loss of gastric fluids. Elevated sodium levels are not expected in this situation.

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Correct Answer is C

Explanation

A. Bradycardia
Bradycardia is not a direct symptom of gastrointestinal perforation. When a perforation occurs, the body's response is often to increase the heart rate (tachycardia) due to the stress and shock.

B. Report of epigastric fullness
Epigastric fullness might be a symptom of peptic ulcer disease but is not specific to gastrointestinal perforation.

C. Severe upper abdominal pain
Correct choice. Severe upper abdominal pain, particularly sudden and intense pain, can be indicative of gastrointestinal perforation. This is a medical emergency and requires immediate attention.

D. Hyperactive bowel sounds
Gastrointestinal perforation can lead to absent or hypoactive bowel sounds due to inflammation and irritation of the abdominal cavity, not hyperactive bowel sounds.

A. Percuss B. Auscultate. C. Palpate. D. Inspect

Correct Answer is D

Explanation

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

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A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 ml. In the past 6 hr. The nurse should monitor the client for which of the following electrolyte Imbalances?

Nursing Test Bank

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