A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take?
Irrigate the NG tube.
Elevate the foot of the bed.
Give the ordered antacid.
Check the vital signs.
The Correct Answer is D
The nurse should quickly assess the patient's vital signs to check for signs of shock and instability. If the vital signs are unstable, the nurse should initiate appropriate interventions to stabilize the patient, such as administering oxygen, starting IV fluids, and providing continuous cardiac monitoring. Based on the sudden onset of severe upper abdominal pain, diaphoresis, and a firm abdomen, the nurse should suspect a possible perforation or bleeding related to the peptic ulcer. This is a medical emergency that requires immediate intervention. Therefore, the nurse should prioritize notifying the healthcare provider and preparing the patient for urgent medical evaluation.
Option A, irrigating the NG tube, is not appropriate in this situation and may further exacerbate the patient's condition if the ulcer has perforated.
Option B, elevating the foot of the bed, is also not appropriate as it does not address the patient's current symptoms.
Option C, giving the ordered antacid, may not be effective in addressing the severity of the patient's symptoms and should be postponed until the healthcare provider has evaluated the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
b. Monitoring blood glucose levels: This is an essential nursing intervention as patients with Cushing syndrome are at risk for developing diabetes mellitus because of cortisol on glucose metabolism. The nurse should monitor the patient's blood glucose levels regularly and report any abnormal readings to the healthcare provider.
c. Protecting patients from exposure to infection: Patients with Cushing syndrome are also at risk for developing infections due to the immunosuppressive effects of cortisol. The nurse should take appropriate infection control measures, such as frequent handwashing, wearing gloves, and isolation precautions if necessary.
a. Observing for signs of hypotension: Although hypotension is not typically seen in patients with Cushing syndrome, it can occur in some cases due to the depletion of cortisol. The nurse should monitor the patient's blood pressure regularly and report any abnormal readings to the healthcare provider.
Correct Answer is D
Explanation
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. The initial management of DKA involves fluid resuscitation with intravenous normal saline to correct dehydration and electrolyte imbalances. Therefore, starting an infusion of normal saline at 125 ml/hr is the first prescribed action the nurse should implement.
Bringing the patient a meal is not a priority at this time because the patient's blood glucose levels need to be stabilized before they can safely consume food. Administering Lantus insulin IV and giving sodium bicarbonate 50 mEq IV push are also not the first-line treatments for DKA. Lantus insulin is a long-acting insulin used to treat hyperglycemia over an extended period and should not be given intravenously. Sodium bicarbonate may be used to correct acidosis, but it is not the first priority in DKA management.
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