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 ["A","B","D","E","F","G","H","J"]
Explanation
● Weight 98 lbs: This information helps determine the patient's baseline weight and assess for potential weight loss associated with dehydration.
● Dehydrated: The diagnosis of dehydration indicates a critical condition that requires immediate attention and intervention.
● Lethargy: Lethargy suggests a decreased level of consciousness and could indicate a severe state of dehydration or other underlying issues that need to be addressed promptly.
● HR 122: A heart rate of 122 beats per minute is elevated and may indicate compensatory mechanisms in response to dehydration or other underlying conditions. It requires further evaluation and intervention.
● Shortness of Breath: This symptom suggests respiratory distress and may be related to the patient's dehydration or underlying conditions. It requires immediate assessment and intervention.
● Temperature 100: An elevated temperature may indicate an underlying infection or inflammatory response. It requires further evaluation to determine the cause and guide appropriate treatment.
● Thirsty: The patient's report of feeling thirsty is an important symptom indicating dehydration and the need for fluid replacement.
● BP 90/50: A blood pressure of 90/50 is low and may be indicative of hypotension, which can occur in dehydration. It requires close monitoring and intervention to stabilize the patient's blood pressure.
The following items are not immediate concerns based on the given information: ● Admitted to the ER: While it is important information, it is not a current concern as the patient is already in the ER.
● Female: The patient's gender is not an immediate concern for the assessment and management of dehydration.
Correct Answer is B
Explanation
Pain tolerance refers to the maximum level of pain that an individual can tolerate without significant distress. It is influenced by various factors, including psychological and emotional factors. While emotions such as anger, boredom, and introversion can have an impact on a person's pain perception and experience, sleep plays a significant role in pain tolerance. During sleep, the body is in a state of rest and relaxation, allowing for decreased sensory input and potentially reducing pain perception. Sleep provides an opportunity for the body to repair and heal, which can contribute to improved pain tolerance. Additionally, sleep promotes the release of endogenous opioids, which are natural pain-relieving substances produced by the body.
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