A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?
Bradycardia
Hyperactive bowel sounds
Report of epigastric fullness
Severe upper abdominal pain
The Correct Answer is D
Choice A: Bradycardia. This is not a manifestation of gastrointestinal perforation, but rather a sign of vagal stimulation, which can occur in response to gastric distension, vomiting, or suctioning. Vagal stimulation can slow down the heart rate and lower the blood pressure.
Choice B: Hyperactive bowel sounds. This is not a manifestation of gastrointestinal perforation, but rather a sign of increased intestinal motility, which can occur in response to inflammation, infection, or irritation of the gastrointestinal tract. Hyperactive bowel sounds are loud, high-pitched, and frequent.
Choice C: Report of epigastric fullness. This is not a manifestation of gastrointestinal perforation, but rather a sign of delayed gastric emptying, which can occur in response to gastric outlet obstruction, gastroparesis, or pyloric stenosis. Epigastric fullness is a feeling of pressure or discomfort in the upper abdomen after eating.
Choice D: Severe upper abdominal pain. This is a manifestation of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. Peptic ulcer disease is a condition that causes erosion and ulceration of the mucosal lining of the stomach or duodenum. If the ulcer penetrates through the wall of the gastrointestinal tract, it can cause perforation, which is a hole that allows gastric contents to leak into the peritoneal cavity. This can cause peritonitis, which is an inflammation and infection of the peritoneum. Peritonitis can cause severe upper abdominal pain, which may radiate to the shoulder or back. The pain may be sudden, sharp, and constant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Docusate. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Docusate is a stool softener that can prevent constipation and straining, but it is not indicated for ulcerative colitis.
Choice B: A corticosteroid medication. This is a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis, which is a chronic inflammatory bowel disease that causes ulcers and inflammation in the colon and rectum. A corticosteroid medication, such as prednisone, can reduce inflammation, suppress the immune system, and relieve symptoms such as diarrhea, bleeding, and pain.
Choice C: Aspirin. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can relieve pain and inflammation, but it can also irritate the gastrointestinal mucosa and worsen ulcerative colitis.
Choice D: A bowel cathartic medication. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. A bowel cathartic medication, such as bisacodyl, can stimulate bowel movements and cleanse the colon, but it can also cause dehydration, electrolyte imbalance, and aggravate ulcerative colitis.
Correct Answer is D
Explanation
Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.
Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.
Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.
Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.
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