A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?
Check the patency of the NG tube.
Place the patient in a recumbent position.
Encourage the patient to deep breathe and consciously relax.
Assess the patient's vital signs and circulatory status.
The Correct Answer is D
The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.
While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.
Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Pancytopenia refers to a decrease in all three major blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). It is a potentially serious side effect that can lead to increased susceptibility to infections, anemia-related symptoms (fatigue, weakness), and an increased risk of bleeding. Prompt reporting is necessary for further
evaluation and appropriate management.
While melena (dark, tarry stools) is a concerning side effect, it typically indicates gastrointestinal bleeding, which should also be reported promptly but may not require immediate action unless the bleeding is severe or accompanied by other symptoms.
Decreased vision can be a side effect of certain medications, including NSAIDs, but it does not usually require immediate reporting unless it is severe or rapidly progressive. Hyperglycemia (high blood sugar) can occur with NSAID therapy, especially in individuals with preexisting diabetes or impaired glucose tolerance. While it should be monitored and managed appropriately, it does not typically require immediate reporting unless it is extremely high or associated with other concerning symptoms.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Ensure the client receives adequate amounts of fluids: This is important to maintain hydration and thin respiratory secretions, making it easier for the client to cough and clear the airways. Check the client's mouth for stomatitis: Methylprednisolone can increase the risk of developing oral candidiasis (thrush) or stomatitis, which can cause discomfort and interfere with oral intake. Regular mouth checks can help identify these conditions early for appropriate management. Assess the client's mental status: Pneumonia, particularly in individuals with pre-existing lung disease like COPD, can lead to hypoxemia, which may affect mental status. It is important to monitor the client's mental status, as changes in cognition or confusion can be indicators of hypoxia and require prompt intervention.
Monitor for signs of hypokalemia: Methylprednisolone, like other corticosteroids, can cause electrolyte imbalances, including hypokalemia (low potassium levels). Hypokalemia can have various effects on the body, including muscle weakness and cardiac dysrhythmias. Regular monitoring of potassium levels and signs of hypokalemia is important for timely management. Monitor the client's blood glucose levels: Methylprednisolone can increase blood glucose levels, particularly in individuals with pre-existing diabetes or impaired glucose tolerance. Regular monitoring of blood glucose levels is necessary to ensure proper glycemic control and prevent hyperglycemia-related complications.
Monitor the client's blood pressure for hypotension: Corticosteroids like methylprednisolone can cause fluid retention, leading to an increase in blood pressure. However, sudden withdrawal of corticosteroids can result in adrenal insufficiency and hypotension. Close monitoring of blood pressure is necessary to identify any significant changes and adjust the medication regimen accordingly.
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