A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?
Insert a nasogastric tube (NGT) and attach to low intermittent suction.
Give a prescribed analgesic for temperature above 101°F (38.3° C).
Place an indwelling urinary catheter and attach a bedside drainage unit.
Send the client to x-ray for a flat plate of the abdomen.
The Correct Answer is A
Choice A reason: Inserting a nasogastric tube (NGT) and attaching to low intermittent suction is the priority intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. This can help decompress the stomach, remove gastric contents, prevent further bleeding, and relieve the symptoms. The NGT should be inserted carefully and checked for proper placement before suctioning.
Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3° C) is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Temperature elevation can indicate infection or inflammation, which can be treated with antibiotics or anti-inflammatory drugs. However, analgesics can have adverse effects on the gastrointestinal tract, such as irritation, ulceration, or bleeding. Analgesics should be given cautiously and after the cause of the fever is identified.
Choice C reason: Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Urinary catheterization can help monitor the fluid balance, renal function, and blood loss of the client, but it is not a priority in this situation. Urinary catheterization can also pose risks of infection, trauma, or obstruction, and should be avoided unless necessary.
Choice D reason: Sending the client to x-ray for a flat plate of the abdomen is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. X-ray can help diagnose the location and extent of the ulcer, perforation, or obstruction, but it is not a priority in this situation. X-ray can also expose the client to radiation, which can be harmful, and should be done only after the client is stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Wearing clothing to cover the radiation site is a correct action, as it can protect the skin from sun exposure, irritation, and infection. The clothing should be loose-fitting, soft, and made of natural fibers, such as cotton or linen. The clothing should also be changed daily and washed separately from other clothes.
Choice B reason: Washing the radiation site with antibacterial soap and water is an incorrect action, as it can dry out, damage, or inflame the skin. The skin in the radiation site is more sensitive and vulnerable to injury and infection. The client should use mild, unscented soap and water to gently cleanse the area once a day, and avoid rubbing or scrubbing the skin.
Choice C reason: Applying prescribed lotions to the radiation site is a correct action, as it can moisturize, soothe, and heal the skin. The client should use only the lotions that are recommended by the health care provider, and avoid any products that contain alcohol, perfume, or other irritants. The client should also apply the lotions at least one hour before or after the radiation treatment, and not during the treatment.
Choice D reason: Drying the area with patting motions after taking a shower is a correct action, as it can prevent friction and trauma to the skin. The client should use a soft, clean towel to gently pat the skin dry, and avoid rubbing or pulling the skin. The client should also avoid using hair dryers, heating pads, or ice packs on the radiation site.
Correct Answer is B
Explanation
Choice A reason: Corticosteroid cream was applied to eczema is not a useful information in determining the possible cause of the symptoms, because it is a treatment that can reduce the inflammation and itching of eczema, not a trigger that can worsen it. Corticosteroid cream should be used as prescribed by the doctor, and the nurse should instruct the client on how to apply it correctly and safely.
Choice B reason: A grandson and his new dog recently visited is a useful information in determining the possible cause of the symptoms, because it can indicate that the client was exposed to an allergen or an irritant that can trigger an eczema flare-up. Some people with eczema may have allergic reactions to animal dander, saliva, or fur, which can cause skin inflammation, redness, and itching. The nurse should ask the client about their history of allergies and their contact with the dog, and advise them to avoid or minimize exposure to potential allergens.
Choice C reason: An old friend with eczema came for a visit is not a useful information in determining the possible cause of the symptoms, because eczema is not a contagious condition that can be transmitted from person to person. Eczema is a chronic skin disorder that causes dry, itchy, and inflamed skin, and it is influenced by genetic, environmental, and immune factors. The nurse should reassure the client that eczema is not infectious and that they can maintain social relationships with other people with eczema.
Choice D reason: Recently received an influenza immunization is not a useful information in determining the possible cause of the symptoms, because there is no evidence that influenza immunization can cause or worsen eczema. Influenza immunization is a preventive measure that can protect the client from getting the flu, which can be a serious and sometimes fatal illness, especially for people with chronic conditions, such as eczema. The nurse should encourage the client to get vaccinated for influenza and other diseases, as recommended by the doctor.
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