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 D
Explanation
Diabetes insipidus is a condition in which the body is unable to properly regulate fluid balance, leading to excessive urination (polyuria) and thirst. Therefore, the nurse should anticipate the clinical manifestation of polyuria in a patient admitted to the hospital with diabetes insipidus. The patient may excrete large amounts of dilute urine, which can lead to dehydration if adequate fluid replacement is not provided. The other options listed (fluid volume overload, decreased gas exchange, and generalized edema) are not typically associated with diabetes insipidus, as this condition is characterized by a deficiency of antidiuretic hormone (ADH) rather than an excess of fluid.
Correct Answer is ["C","D"]
Explanation
Option A is not the best advice because drinking lots of water alone may not be enough to relieve constipation, especially if there is an obstruction.
Option B is also not accurate because not all intestinal obstructions require surgery, and the treatment approach will depend on the cause and severity of the obstruction.
Option C is accurate because a nasogastric tube can help relieve any distention caused by the obstruction by removing any gas or fluids that may have accumulated in the stomach and small intestine.
Option D is also accurate because an abdominal CT is one of the diagnostic tests that can help confirm the presence of intestinal obstruction and provide information about the location and cause of the obstruction.
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