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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.

Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.

A. administration of antiemetics B. administration of diuretics C. Possible Electrolyte replacement if warranted D. Administration of IV 0.9 Saline Solution infusion E. Have the patient go home and rest. It will resolve itself shortly.

Correct Answer is D

Explanation

Mrs. Kalen is diagnosed with gastroenteritis and dehydration, and the arterial blood gas results indicate metabolic alkalosis (elevated pH and HCO3-). This suggests that there is an excessive loss of gastric acid and chloride ions from vomiting, leading to an imbalance of electrolytes and an increase in bicarbonate levels.

To correct the imbalance and treat dehydration, the primary intervention is fluid replacement. Administration of IV 0.9 Saline Solution, also known as normal saline, is commonly used for fluid resuscitation and rehydration. This isotonic solution helps restore fluid balance and electrolyte levels in the body.

Administration of antiemetics may help control vomiting, but the primary treatment focus in this case is fluid and electrolyte replacement to correct dehydration and the associated metabolic alkalosis.

Administration of diuretics, which increase urine output, would not be appropriate in this case as the patient is already experiencing dehydration.

Electrolyte replacement may be necessary if there are specific electrolyte imbalances identified, but the primary treatment is fluid replacement with IV saline solution.

Having the patient go home and rest without addressing the underlying dehydration and metabolic alkalosis would not be appropriate as it can lead to further complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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