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 B
Explanation
Since the patient's blood glucose level is less than 70 mg/dL and they are symptomatic, the first step is to administer 1 mg Glucagon IM. This will help increase the patient's blood glucose level quickly.
After administering Glucagon, the nurse should then call the MD to report the low blood glucose level and discuss any necessary adjustments to the patient's insulin regimen. It is important to note that in this situation, administering Humalog insulin would further lower the patient's blood glucose level and could worsen their symptoms. Encouraging the patient to eat their meal is also important, but it should be done after the administration of Glucagon to help maintain their blood glucose level.
Correct Answer is C
Explanation
The patient's vital signs suggest that she is experiencing hypotension, tachycardia, and possibly dehydration due to acute adrenal insufficiency. The highest priority nursing intervention for this patient is to provide isotonic fluids to restore intravascular volume and blood pressure. This will also help to correct any electrolyte imbalances that may be present. Administering furosemide (Lasix) or replacing potassium losses may be necessary interventions, but they are not the highest priority at this time. Restricting sodium would be contraindicated in this situation as the patient is hypotensive and needs fluids to increase intravascular volume.
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