A nurse is gathering data from a client who has peptic ulcer disease. Which of the following findings is a sign of gastrointestinal perforation?

Bradycardia

Hyperactive bowel sounds

Severe upper abdominal pain

Report of epigastric fullness

Answer and Explanation

The Correct Answer is C

Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
Choice B rationale
Hyperactive bowel sounds are not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
Choice C rationale
Severe upper abdominal pain is a common sign of gastrointestinal perforation in peptic ulcer disease25. The pain is often sudden and severe, and it may spread to the back or shoulder.
Choice D rationale
A report of epigastric fullness is not typically a sign of gastrointestinal perforation in peptic ulcer disease25.

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Correct Answer is C

Explanation

Choice A rationale
Absence of bowel sounds can be a normal finding post-operatively and is not necessarily a cause for concern.
Choice B rationale
A small amount of bloody drainage on the dressing is not uncommon after surgery and is not typically a cause for concern.
Choice C rationale
A rigid abdomen on palpation is a concerning finding after an appendectomy. It could indicate peritonitis, a serious infection of the abdominal cavity that can occur if the appendix burst before or during surgery.
Choice D rationale
Pain at the operative site is expected after an appendectomy. However, severe or increasing pain could indicate a complication and should be evaluated by a healthcare provider.

A. Monitor peripheral pulses every 8 hours B. Measure urine output every 4 hours C. Maintain NPO status D. Ambulate the patient three times daily

Correct Answer is C

Explanation

Choice A rationale
Monitoring peripheral pulses every 8 hours is not typically a priority in the care plan for a patient with acute pancreatitis. While cardiovascular monitoring is important in all patients, it is not specifically related to the management of acute pancreatitis.
Choice B rationale
Measuring urine output every 4 hours can be important in assessing fluid balance and kidney function, but it is not the primary intervention in the care plan for a patient with acute pancreatitis.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a key intervention in the management of acute pancreatitis. This helps to rest the pancreas and reduce the production of digestive enzymes.
Choice D rationale
Ambulating the patient three times daily is generally a good practice for postoperative recovery, but it is not specific to the care of a patient with acute pancreatitis. In the acute phase of pancreatitis, rest is often recommended.

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A nurse is gathering data from a client who has peptic ulcer disease. Which of the following findings is a sign of gastrointestinal perforation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding is most concerning?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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