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 ["B","C","D","E","F"]
Explanation
The normal physiological changes of aging that the nurse can expect in an older adult during a musculoskeletal assessment include:
● Widened Gait: With age, there can be a natural widening of the gait due to changes in balance and stability.
● Kyphosis: Kyphosis refers to an increased curvature of the thoracic spine, commonly known as a "hunchback" appearance, which can occur due to changes in the vertebral bones and intervertebral discs.
● Slowed movement: Older adults may experience a natural decline in their movement speed due to changes in muscle strength, coordination, and reaction time. ● Muscle atrophy: Age-related muscle atrophy, or loss of muscle mass, can occur, particularly if the older adult leads a sedentary lifestyle or has other underlying health conditions.
● Decreased joint ROM (Range of Motion): Older adults may experience a gradual decrease in joint flexibility and range of motion due to changes in the joints, ligaments, and surrounding tissues. This can affect their ability to move joints fully.
It's important to note that while some older adults may develop arthritis, it is not considered a normal physiological change of aging. Arthritis refers to the inflammation and degeneration of joints, which can occur due to various factors, including age, genetics, and lifestyle.
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
